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Kon H, Hameir A, Nutman A, Temkin E, Keren Paz A, Lellouche J, Schwartz D, Weiss DS, Kaye KS, Daikos GL, Skiada A, Durante-Mangoni E, Dishon Benattar Y, Yahav D, Daitch V, Bernardo M, Iossa D, Friberg LE, Theuretzbacher U, Leibovici L, Dickstein Y, Pollak D, Mendelsohn S, Paul M, Carmeli Y. Prevalence and Clinical Consequences of Colistin Heteroresistance and Evolution into Full Resistance in Carbapenem-Resistant Acinetobacter baumannii. Microbiol Spectr 2023; 11:e0509322. [PMID: 37219426 PMCID: PMC10269815 DOI: 10.1128/spectrum.05093-22] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/08/2023] [Indexed: 05/24/2023] Open
Abstract
Colistin heteroresistance (HR) refers to a bacterial population comprised of several subpopulations with different levels of resistance to colistin. In this study, we discuss the classic form of HR, in which a resistant subpopulation exists within a predominantly susceptible population. We investigated the prevalence of colistin HR and its evolution into full resistance among 173 clinical carbapenem-resistant Acinetobacter baumannii isolates and examined the effect of HR on clinical outcomes. To determine HR, we performed population analysis profiling. Our results showed a high prevalence of HR (67.1%). To examine evolution of HR strains into full resistance, the HR strains were grown in colistin-containing broth, transferred onto colistin-containing plates, and colonies on these plates were transferred into colistin-free broth. Many of the HR strains (80.2%) evolved into full resistance, 17.2% reverted to HR, and 2.6% were borderline. We used logistic regression to compare 14-day clinical failure and 14-day mortality between patients infected by HR versus susceptible non-HR carbapenem-resistant A. baumannii. In the subgroup of patients with bacteremia, HR was significantly associated with 14-day mortality. IMPORTANCE To our knowledge, this is the first large-scale study to report on HR in Gram-negative bacteria. We described the prevalence of colistin HR in a large sample of carbapenem-resistant A. baumannii isolates, the evolution of many colistin HR isolates to a resistant phenotype following colistin exposure and withdrawal, and the clinical consequences of colistin HR. We found a high prevalence of HR among clinical carbapenem-resistant A. baumannii isolates; most evolved into a resistant phenotype following colistin exposure and withdrawal. In patients treated with colistin, evolution of HR A. baumannii into full resistance could lead to higher rates of treatment failure and contribute to the reservoir of colistin-resistant pathogens in health care settings.
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Affiliation(s)
- Hadas Kon
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Amichay Hameir
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Amir Nutman
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elizabeth Temkin
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Alona Keren Paz
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Jonathan Lellouche
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
- Adelson School of Medicine, Ariel University, Israel
| | - David Schwartz
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - David S. Weiss
- Emory Antibiotic Resistance Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Keith S. Kaye
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - George L. Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece
- National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Skiada
- First Department of Medicine, Laikon General Hospital, Athens, Greece
- National and Kapodistrian University of Athens, Athens, Greece
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
- AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Yael Dishon Benattar
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Dafna Yahav
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Vered Daitch
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Mariano Bernardo
- Microbiology and Virology Unit, AORN Ospedali dei Colli-Monaldi Hospital, Naples, Italy
| | - Domenico Iossa
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | | | - Leonard Leibovici
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Dina Pollak
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Sigal Mendelsohn
- Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Paul M, Dishon-Benattar Y, Dickstein Y, Yahav D. Optimizing patient recruitment into clinical trials of antimicrobial-resistant pathogens. JAC Antimicrob Resist 2023; 5:dlad005. [PMID: 36726533 PMCID: PMC9883721 DOI: 10.1093/jacamr/dlad005] [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: 01/30/2023] Open
Abstract
Recruitment of patients with critical priority antimicrobial-resistant (AMR) bacteria into drug approval randomized controlled trials (RCTs) has not been successful to date. Approaching from the viewpoint of clinician-investigators and learning from the experience of AMR-focused investigator-initiated trials, we present suggestions to improve feasibility and efficiency of RCTs evaluating patients with severe infections caused by carbapenem-resistant Gram-negative or other AMR bacteria. Considerations address the trials' eligibility criteria, whether the focus of the trial is pathogen- or syndrome-targeted, trials' case report forms and monitoring, informed consent strategies for the recruitment of extremely ill patients, team dedication and incentives to run the trial and alternative trial designs. Evidence on the effects of new drugs against the AMR that these drugs target is weak and needs to be improved through better industry-academic collaboration, taking advantage of the different strengths of industry-led and investigator-initiated research.
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Affiliation(s)
| | - Yael Dishon-Benattar
- Infectious Diseases Division, Rambam Health Care Campus, Haifa, Israel,The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Division, Rambam Health Care Campus, Haifa, Israel,The Ruth and Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel,Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
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Turjeman A, Koppel F, Franceschini E, Yahav D, Dolci G, Bacca E, Babich T, Khazem E, Baum E, Nassar R, Bitterman R, Dishon-Benatta Y, Hassoun-Kheir N, Santoro A, Eliakim-Raz N, Poran I, Pertzov B, Stern A, Dickstein Y, Maroun E, Raines M, Meschiari M, Bishara J, Goldberg E, Venturelli C, Sarti M, Mussini C, Paul M, Leibovici L. External Validity of a Randomized Controlled Trial on Duration of Antibiotics for the Treatment of Gram-Negative Bacteremia. Gerontology 2023; 69:312-320. [PMID: 36273449 DOI: 10.1159/000526480] [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: 03/24/2022] [Accepted: 07/19/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Reports regarding the external validity of randomized controlled trials (RCTs) are scarce. We aimed to assess the population external validity of an investigator-initiated RCT on the duration of antibiotics for the treatment of Gram-negative bacteremia by comparing patients included in the RCT to patients that were not included in the trial. METHODS Hospitalized patients with Gram-negative bacteremia were recruited into an RCT and randomized to receive 7 or 14 days of covering antibiotic therapy in Israel and Italy from 2013 to 2017. In a concomitant observational study, RCT participants were compared with patients who fulfilled the inclusion criteria but were not included in the trial due to participation in other trials, discharge before approached by researchers, refusal to participate, or unwillingness of the treating physician to allow participants' recruitment. RESULTS Six hundred and four RCT patients were compared with 613 nonincluded patients. Almost 50% of nonincluded patients (288/613) were dependent on others for activities of daily living at baseline compared to 37.7% of RCT participants (228/604). Dementia was nearly 2-fold more frequent in nonincluded patients than those included (5.9% [36/613] versus 3.6% [22/604], p = 0.07). Patients who were not included in the RCT were more likely to acquire their infection in the hospital (53.3% [327/613] versus 29.1% [176/604], p < 0.001). The primary composite outcome of mortality, clinical failure, readmissions, or extended hospitalization at 90 days occurred in 353 of 613 nonincluded patients (57.6%) compared to 299 of 604 RCT participants (49.6%), p = 0.005. However, on multivariate analysis noninclusion in the RCT was not an independent risk factor for clinical failure and mortality. CONCLUSIONS RCTs, even with broad eligibility criteria, do not represent the whole spectrum of patients and leave out a population with more severe illness for whom the evidence is lacking.
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Affiliation(s)
- Adi Turjeman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Giovanni Dolci
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Bacca
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Tanya Babich
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ebtehal Khazem
- Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel
| | - Eyal Baum
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Rima Nassar
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Yael Dishon-Benatta
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Antonella Santoro
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itamar Poran
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Barak Pertzov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pulmonary Division, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Elias Maroun
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Marina Raines
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Marianna Meschiari
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Jihad Bishara
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Claudia Venturelli
- Clinical Microbiology Lab, University of Modena and Reggio Emilia, Modena, Italy
| | - Mario Sarti
- Clinical Microbiology Lab, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Fattah MA, Haquin J, Macgowan A, Grier S, Chazan B, Yanovskay A, Ami RB, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Mauer S, Rodríguez-Baño J, de Cueto M, Oliver A, de Gopegui ER, Cano A, Machuca I, Gozalo-Marguello M, Martinez-Martinez L, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Duration of Treatment for Pseudomonas aeruginosa Bacteremia: a Retrospective Study. Infect Dis Ther 2022; 11:1505-1519. [PMID: 35612693 PMCID: PMC9334465 DOI: 10.1007/s40121-022-00657-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION There is no consensus regarding optimal duration of antibiotic therapy for Pseudomonas aeruginosa bacteremia. We aimed to evaluate the impact of short antibiotic course. METHODS We present a retrospective multicenter study including patients with P. aeruginosa bacteremia during 2009-2015. We evaluated outcomes of patients treated with short (6-10 days) versus long (11-15 days) antibiotic courses. The primary outcome was a composite of 30-day mortality or bacteremia recurrence and/or persistence. Univariate and inverse probability treatment-weighted (IPTW) adjusted multivariate analysis for the primary outcome was performed. To avoid immortal time bias, the landmark method was used. RESULTS We included 657 patients; 273 received a short antibiotic course and 384 a long course. There was no significant difference in baseline characteristics of patients. The composite primary outcome occurred in 61/384 patients in the long-treatment group (16%) versus 32/273 in the short-treatment group (12%) (p = 0.131). Mortality accounted for 41/384 (11%) versus 25/273 (9%) of cases, respectively. Length of hospital stay was significantly shorter in the short group [median 13 days, interquartile range (IQR) 9-21 days, versus median 15 days, IQR 11-26 days, p = 0.002]. Ten patients in the long group discontinued antibiotic therapy owing to adverse events, compared with none in the short group. On univariate and multivariate analyses, duration of therapy was not associated with the primary outcome. CONCLUSIONS In this retrospective study, 6-10 days of antibiotic course for P. aeruginosa bacteremia were as effective as longer courses in terms of survival and recurrence. Shorter therapy was associated with reduced length of stay and less drug discontinuation.
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Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Rabin Medical Center, Research Authority, Beilinson Hospital, Petah-Tikva, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- Université de Lorraine, APEMAC, 54000, Nancy, France.,Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Manal Abdel Fattah
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Justine Haquin
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Alasdair Macgowan
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Sally Grier
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Bibiana Chazan
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion, Emek Medical Center, Afula, Haifa, Israel
| | - Anna Yanovskay
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion, Emek Medical Center, Afula, Haifa, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Michal Landes
- Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Evelina Tacconelli
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Michael Buhl
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Susanna Mauer
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Jesús Rodríguez-Baño
- Departamentos de Medicina y Microbiología, Unidad Clínica de Enfermedades Infecciosas and Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Seville, Spain
| | - Marina de Cueto
- Departamentos de Medicina y Microbiología, Unidad Clínica de Enfermedades Infecciosas and Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Seville, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma, Spain
| | - Enrique Ruiz de Gopegui
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma, Spain
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | | | - Luis Martinez-Martinez
- Microbiology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Leonardo Pagani
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Virginie Vitrat
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Rabin Medical Center, Research Authority, Beilinson Hospital, Petah-Tikva, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, 2 Sheba Road, 52621, Ramat-Gan, Israel.
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5
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Turjeman A, Koppel F, Franceschini E, Yahav D, Dolci G, Babich T, Bitterman R, Neuberger A, Ghanem-Zoubi N, Santoro A, Eliakim-Raz N, Pertzov B, Stern A, Dickstein Y, Maroun E, Zayyad H, Meschiari M, Bishara J, Goldberg E, Venturelli C, Mussini C, Paul M, Leibovici L. Risk factors for functional decline among survivors of Gram-negative bloodstream infection: A prospective cohort study. PLoS One 2021; 16:e0259707. [PMID: 34788325 PMCID: PMC8598031 DOI: 10.1371/journal.pone.0259707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify risk factors for functional decline after hospitalization for Gram-negative bacteremia. PATIENTS AND METHODS A prospective cohort study based on a randomized controlled trial conducted between January 1, 2013 and August 31, 2017 in Israel and Italy. Hospitalized patients with Gram-negative bacteremia who survived until day 90 and were not bedridden at baseline were included. The primary end point was functional decline at 90 days. RESULTS Five hundred and nine patients were included. The median age of the cohort was 71 years (interquartile range [IQR], 60-80 years), 46.4% (236/509) were male and 352 of 509 (69%) patients were independent at baseline. Functional decline at 90 days occurred in 24.4% of patients (124/509). In multivariable analysis; older age (odds ratio [OR], 1.03; for an one-year increment, 95% confidence interval [CI] 1.01-1.05), functional dependence in instrumental activities of daily living at baseline (OR, 4.64; 95% CI 2.5-8.6), low Norton score (OR, 0.87; 95% CI 0.79-0.96) and underlying comorbidities: cancer (OR, 2.01; 95% CI 1.14-3.55) and chronic pulmonary disease (OR, 2.23 95% CI 1.12-4.42) and longer length of hospital stay (OR 1.09; for one-day increment, 95% CI 1.04-1.15) were associated with functional decline. Appropriate empirical antibiotic treatment was associated with lower rates of functional decline within 90 days (OR, 0.4; 95% CI 0.21-0.78). CONCLUSIONS Patients surviving bloodstream infections have poor long term trajectories after clinical recovery and hospital discharge. This has vast implications for patients, their family members and health policy makers.
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Affiliation(s)
- Adi Turjeman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Giovanni Dolci
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Tanya Babich
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Ami Neuberger
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Nesrin Ghanem-Zoubi
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Antonella Santoro
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barak Pertzov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pulmonary Division, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Elias Maroun
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Marianna Meschiari
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Jihad Bishara
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Claudia Venturelli
- Clinical Microbiology Lab, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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6
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Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Abdel Fattah M, Haquin J, MacGowan A, Grier S, Gibbs J, Chazan B, Yanovskay A, Ami RB, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Mauer S, Rodriguez-Bano J, Morales I, Oliver A, Ruiz de Gopegui E, Cano A, Machuca I, Gozalo-Marguello M, Martinez LM, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Combination versus monotherapy as definitive treatment for Pseudomonas aeruginosa bacteraemia: a multicentre retrospective observational cohort study. J Antimicrob Chemother 2021; 76:2172-2181. [PMID: 33993273 DOI: 10.1093/jac/dkab134] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/31/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pseudomonas aeruginosa bacteraemia is a common and serious infection. No consensus exists regarding whether definitive combination therapy is superior to monotherapy. We aimed to evaluate the impact of combination therapy on mortality. METHODS This was a multicentre retrospective study (nine countries, 25 centres), including 1277 patients with P. aeruginosa bacteraemia during 2009-15. We evaluated the association between β-lactam plus aminoglycoside or quinolone combination therapy versus β-lactam monotherapy and mortality. The primary outcome was 30 day all-cause mortality. Univariate and multivariate Cox regression analyses were conducted, introducing combination as a time-dependent variable. Propensity score was conducted to adjust for confounding for choosing combination therapy over monotherapy. RESULTS Of 1119 patients included, 843 received definitive monotherapy and 276 received combination therapy (59% aminoglycoside and 41% quinolone). Mortality at 30 days was 16.9% (189/1119) and was similar between combination (45/276; 16.3%) and monotherapy (144/843; 17.1%) groups (P = 0.765). In multivariate Cox regression, combination therapy was not associated with reduced mortality (HR 0.98, 95% CI 0.64-1.53). No advantage in terms of clinical failure, microbiological failure or recurrent/persistent bacteraemia was demonstrated using combination therapy. Likewise, adverse events and resistance development were similar for the two regimens. CONCLUSIONS In this retrospective cohort, no mortality advantage was demonstrated using combination therapy over monotherapy for P. aeruginosa bacteraemia. Combination therapy did not improve clinical or microbiological failure rates, nor affect adverse events or resistance development. Our finding of no benefit with combination therapy needs confirmation in well-designed randomized controlled trials.
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Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet and Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- Université de Lorraine, APEMAC, F-54000, Nancy, France
- Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, F-54000, Nancy, France
| | - Manal Abdel Fattah
- Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, F-54000, Nancy, France
| | - Justine Haquin
- Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, F-54000, Nancy, France
| | - Alasdair MacGowan
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Sally Grier
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Julie Gibbs
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Bibiana Chazan
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Anna Yanovskay
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Israel
- Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Michal Landes
- Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Evelina Tacconelli
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Michael Buhl
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Susanna Mauer
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Jesus Rodriguez-Bano
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Isabel Morales
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Antonio Oliver
- Servicio de Microbiología & Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Enrique Ruiz de Gopegui
- Servicio de Microbiología & Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain
| | | | - Luis Martinez Martinez
- Microbiology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Ljubljana; Faculty of Medicine, University of Ljubljana, Slovenia
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Ljubljana; Faculty of Medicine, University of Ljubljana, Slovenia
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Virginie Vitrat
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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7
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Dickstein Y, Solter E, Schwartz D, Nutman A, Harevrich I, Wulffhart L, Carmeli Y, Schwaber MJ. The Israeli national policy for discontinuation of isolation of carbapenem-resistant Enterobacterales carriers by carbapenemase type: a retrospective cohort study. Clin Microbiol Infect 2021; 27:1518.e1-1518.e3. [PMID: 34111587 DOI: 10.1016/j.cmi.2021.05.045] [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: 11/01/2020] [Revised: 05/13/2021] [Accepted: 05/21/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The Israeli national policy for containing carbapenemase-producing Enterobacterales (CPE) includes a protocol allowing for discontinuation of carrier status following spontaneous decolonization. We examined the strategy's effectiveness based on carbapenemase type. METHODS We performed a retrospective cohort study comparing individuals colonized with KPC- or NDM-producing Enterobacterales who underwent the process of isolation discontinuation. The primary outcome was reversion of carrier status, i.e. re-identification of the same CPE species following isolation discontinuation. We used survival analysis to estimate overall hazard ratio and performed competing-risks analysis using a Fine-Gray subdistribution hazard model and cause-specific hazard ratios. RESULTS Between 1 January 2006 and 1 January 2019 we identified 1694 individuals who met inclusion criteria, including 1337 (78.9%) carriers of KPC-producing Enterobacterales, 305 (18.0%) carriers of NDM-producing Enterobacterales and 52 (3.1%) carriers of dual KPC-/NDM-producing Enterobacterales. A total of 134 individuals (7.9%) had reversion of carrier status: 9.1% (121/1337) and 4.3% (13/305) of individuals with KPC- and NDM-producing Enterobacterales, respectively. The subdistribution hazard ratio of status reversion was not increased among carriers of NDM producers compared with KPC producers (0.567, 95% CI 0.320-1.000], p 0.052). Cause-specific hazard ratios yielded similar results (0.522, 95% CI 0.291-0.937, p 0.029. CONCLUSIONS Carriage of NDM-producing Enterobacterales was not associated with higher rates of reversion to carrier status following spontaneous decolonization than was carriage of KPC-producing Enterobacterales.
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Affiliation(s)
- Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.
| | - Ester Solter
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - David Schwartz
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Amir Nutman
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inga Harevrich
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Liat Wulffhart
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Yehuda Carmeli
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mitchell J Schwaber
- National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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8
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Dickstein Y, Eluk O, Warman S, Aboalheja W, Alon T, Firan I, Putler RKB, Hussein K. Wall painting following terminal cleaning with a chlorine solution as part of an intervention to control an outbreak of carbapenem-resistant Acinetobacter baumannii in a neurosurgical intensive care unit in Israel. J Infect Chemother 2021; 27:1423-1428. [PMID: 34083145 DOI: 10.1016/j.jiac.2021.05.017] [Citation(s) in RCA: 3] [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: 12/17/2020] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND To describe the use of wall painting as part of an intervention to control an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB). METHODS An interrupted time-series analysis was performed analyzing an intervention in a neurosurgical intensive care unit (NSICU) and an inpatient hematology department in a tertiary level medical center in Israel. The intervention involved wall painting using a water based acrylic paint following patient discharge and terminal cleaning with sodium troclosene as part of an infection control bundle for an outbreak of CRAB in a NSICU and concurrent outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) colonization/infection in the same NSICU and the hematology department. RESULTS Between January 2013 and December 2018, 122 patients hospitalized in the NSICU were identified with new CRAB colonization/infection. The median incidence in the periods prior to/post intervention were 2.24/1000 HD (interquartile range [IQR] 0.84-2.90/1000) vs. 0/1000 HD (IQR 0-0.49/1000), respectively. Poisson regression indicated a decrease of 92% in the CRAB incidence following the intervention onset (relative risk [RR] 0.080, 95% confidence interval [CI] 0.037-0.174, p < 0.001). Forty-seven patients in the NSICU and 110 in the hematology department were colonized/infected with CRE in the same time period; a significant change was not observed following the start of the intervention in either department (for NSICU RR 1.236, 95% CI 0.370-4.125, p = 0.731; for hematology RR 0.658, 95% CI 0.314-1.378, p = 0.267). CONCLUSIONS A. baumannii is able to survive on environmental surfaces despite decontamination efforts; wall-painting as part of a bundle may be a successful infection control measure.
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Affiliation(s)
- Yaakov Dickstein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel.
| | - Orna Eluk
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Sigal Warman
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Worood Aboalheja
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Tamar Alon
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Ibrahim Firan
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | | | - Khetam Hussein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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9
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Dickstein Y, Lellouche J, Schwartz D, Nutman A, Rakovitsky N, Dishon Benattar Y, Altunin S, Bernardo M, Iossa D, Durante-Mangoni E, Antoniadou A, Skiada A, Deliolanis I, Daikos GL, Daitch V, Yahav D, Leibovici L, Rognås V, Friberg LE, Mouton JW, Paul M, Carmeli Y. Colistin Resistance Development Following Colistin-Meropenem Combination Therapy Versus Colistin Monotherapy in Patients With Infections Caused by Carbapenem-Resistant Organisms. Clin Infect Dis 2021; 71:2599-2607. [PMID: 31758195 DOI: 10.1093/cid/ciz1146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 08/14/2019] [Accepted: 11/21/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We evaluated whether carbapenem-colistin combination therapy reduces the emergence of colistin resistance, compared to colistin monotherapy, when given to patients with infections due to carbapenem-resistant Gram-negative organisms. METHODS This is a pre-planned analysis of a secondary outcome from a randomized, controlled trial comparing colistin monotherapy with colistin-meropenem combination for the treatment of severe infections caused by carbapenem-resistant, colistin-susceptible Gram-negative bacteria. We evaluated rectal swabs taken on Day 7 or later for the presence of new colistin-resistant (ColR) isolates. We evaluated the emergence of any ColR isolate and the emergence of ColR Enterobacteriaceae (ColR-E). RESULTS Data were available for 214 patients for the primary analysis; emergent ColR organisms were detected in 22 (10.3%). No difference was observed between patients randomized to treatment with colistin monotherapy (10/106, 9.4%) versus patients randomized to colistin-meropenem combination therapy (12/108, 11.1%; P = .669). ColR-E organisms were detected in 18/249 (7.2%) patients available for analysis. No difference was observed between the 2 treatment arms (colistin monotherapy 6/128 [4.7%] vs combination therapy 12/121 [9.9%]; P = .111). Enterobacteriaceae, as the index isolate, was found to be associated with development of ColR-E (hazard ratio, 3.875; 95% confidence interval, 1.475-10.184; P = .006). CONCLUSIONS Carbapenem-colistin combination therapy did not reduce the incidence of colistin resistance emergence in patients with infections due to carbapenem-resistant organisms. Further studies are necessary to elucidate the development of colistin resistance and methods for its prevention.
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Affiliation(s)
- Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Jonathan Lellouche
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - David Schwartz
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Amir Nutman
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Nadya Rakovitsky
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | | | - Sergey Altunin
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Mariano Bernardo
- University of Campania "L. Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Domenico Iossa
- University of Campania "L. Vanvitelli," Monaldi Hospital, Naples, Italy
| | | | - Anastasia Antoniadou
- Fourth Department of Medicine, Attikon University General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Skiada
- National and Kapodistrian University of Athens, Athens, Greece.,First Department of Medicine, Laikon General Hospital, Athens, Greece
| | - Ioannis Deliolanis
- National and Kapodistrian University of Athens, Athens, Greece.,First Department of Medicine, Laikon General Hospital, Athens, Greece
| | - George L Daikos
- National and Kapodistrian University of Athens, Athens, Greece.,First Department of Medicine, Laikon General Hospital, Athens, Greece
| | - Vered Daitch
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Infectious Diseases Unit, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Viktor Rognås
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
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10
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Henderson A, Bursle E, Stewart A, Harris PNA, Paterson D, Chatfield MD, Paul M, Dickstein Y, Rodriguez-Baño J, Turnidge JD, Kahlmeter G. A systematic review of antimicrobial susceptibility testing as a tool in clinical trials assessing antimicrobials against infections due to gram-negative pathogens. Clin Microbiol Infect 2021; 27:1746-1753. [PMID: 33813125 DOI: 10.1016/j.cmi.2021.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/11/2021] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antimicrobial susceptibility testing (AST) is the standard of care for treating bacterial infections. In randomized clinical trials of new antimicrobials, AST might not be performed or reported in real time. OBJECTIVES To determine local, real-time laboratory AST performance, its usage in the trial flow, quality control (QC) of the local testing, central AST performance and the effect of using AST categorization on the trials' primary outcomes. DATA SOURCES We systematically searched PubMed, Embase, PsychINFO and Web of Science. ELIGIBILITY CRITERIA We included registered randomized controlled trials published in journals between January 2015 and December 2019. PARTICIPANTS AND INTERVENTIONS We included trials comparing different antibiotics for the treatment of infections caused predominantly by Gram-negative bacteria. METHODS Primary outcomes for different trial populations were extracted and differences between trial arms were compared for patients with infections caused by susceptible versus non-susceptible bacteria. Results are described narratively. RESULTS Of 32 randomized trials, 25 trials reported that local AST was performed, 1312 reported the local laboratory AST methods, no trial reported QC, but post-hoc referral for AST at a reference laboratory was common. Patients' outcomes were superior when patients with infections due to susceptible and non-susceptible pathogens were compared post hoc (median difference 14%, interquartile range 8%-24%) in trials allowing this comparison (seven antimicrobials), except for colistin, where 14-day mortality was 9% higher when patients were treated with colistin for colistin-susceptible versus colistin-resistant carbapenem-resistant Acinetobacter baumannii. When excluding patients with pathogens that were non-susceptible to either antimicrobial in the trials, the difference in the primary outcome between the trial arms was reduced in five out of six trials. CONCLUSIONS Trials should perform AST to guide patient inclusion or exclusion from the study and consider the impact of the central laboratory susceptibility results on the study outcomes when using post-hoc reference testing.
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Affiliation(s)
- Andrew Henderson
- Princess Alexandra Hospital, Brisbane, QLD, Australia; University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia.
| | - Evan Bursle
- Princess Alexandra Hospital, Brisbane, QLD, Australia; University of Queensland, QLD, Australia; Sullivan and Nicolaides Pathology, Brisbane, QLD, Australia
| | - Adam Stewart
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia; Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Patrick N A Harris
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia; Pathology Queensland, Brisbane, QLD, Australia
| | - David Paterson
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia
| | - Mark D Chatfield
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Jesus Rodriguez-Baño
- Hospital Universitario Virgen Macarena, Sevilla, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Virgen Macarena, Sevilla, Spain; Departamento de Medicina, Universidad de Sevilla and Instituto de Biomedicina de Seville, Sevilla, Spain
| | - John D Turnidge
- University of Adelaide, Adelaide, SA, Australia; European Committee on Antimicrobial Susceptibility Testing (EUCAST), Adelaide, Australia
| | - Gunnar Kahlmeter
- European Committee on Antimicrobial Susceptibility Testing (EUCAST), Adelaide, Australia; European Committee on Antimicrobial Susceptibility Testing (EUCAST), Vaxjo, Sweden
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11
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Daitch V, Paul M, Daikos GL, Durante-Mangoni E, Yahav D, Carmeli Y, Benattar YD, Skiada A, Andini R, Eliakim-Raz N, Nutman A, Zusman O, Antoniadou A, Cavezza G, Adler A, Dickstein Y, Pavleas I, Zampino R, Bitterman R, Zayyad H, Koppel F, Zak-Doron Y, Levi I, Babich T, Turjeman A, Ben-Zvi H, Friberg LE, Mouton JW, Theuretzbacher U, Leibovici L. Excluded versus included patients in a randomized controlled trial of infections caused by carbapenem-resistant Gram-negative bacteria: relevance to external validity. BMC Infect Dis 2021; 21:309. [PMID: 33789574 PMCID: PMC8010276 DOI: 10.1186/s12879-021-05995-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 03/17/2021] [Indexed: 01/19/2023] Open
Abstract
Background Population external validity is the extent to which an experimental study results can be generalized from a specific sample to a defined population. In order to apply the results of a study, we should be able to assess its population external validity. We performed an investigator-initiated randomized controlled trial (RCT) (AIDA study), which compared colistin-meropenem combination therapy to colistin monotherapy in the treatment of patients infected with carbapenem-resistant Gram-negative bacteria. In order to examine the study’s population external validity and to substantiate the use of AIDA study results in clinical practice, we performed a concomitant observational trial. Methods The study was conducted between October 1st, 2013 and January 31st, 2017 (during the RCTs recruitment period) in Greece, Israel and Italy. Patients included in the observational arm of the study have fulfilled clinical and microbiological inclusion criteria but were excluded from the RCT due to receipt of colistin for > 96 h, refusal to participate, or prior inclusion in the RCT. Non-randomized cases were compared to randomized patients. The primary outcome was clinical failure at 14 days of infection onset. Results Analysis included 701 patients. Patients were infected mainly with Acinetobacter baumannii [78.2% (548/701)]. The most common reason for exclusion was refusal to participate [62% (183/295)]. Non-randomized and randomized patients were similar in most of the demographic and background parameters, though randomized patients showed minor differences towards a more severe infection. Combination therapy was less common in non-randomized patients [31.9% (53/166) vs. 51.2% (208/406), p = 0.000]. Randomized patients received longer treatment of colistin [13 days (IQR 10–16) vs. 8.5 days (IQR 0–15), p = 0.000]. Univariate analysis showed that non-randomized patients were more inclined to clinical failure on day 14 from infection onset [82% (242/295) vs. 75.5% (307/406), p = 0.042]. After adjusting for other variables, non-inclusion was not an independent risk factor for clinical failure at day 14. Conclusion The similarity between the observational arm and RCT patients has strengthened our confidence in the population external validity of the AIDA trial. Adding an observational arm to intervention studies can help increase the population external validity and improve implementation of study results in clinical practice. Trial registration The trial was registered with ClinicalTrials.gov, number NCT01732250 on November 22, 2012.
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Affiliation(s)
- Vered Daitch
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel. .,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel.
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - George L Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Emanuele Durante-Mangoni
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yehuda Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Yael Dishon Benattar
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy.,Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Anna Skiada
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Roberto Andini
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Noa Eliakim-Raz
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Amir Nutman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Oren Zusman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Anastasia Antoniadou
- National and Kapodistrian University of Athens, Athens, Greece.,Fourth Department of Medicine, Attikon University General Hospital, Athens, Greece
| | - Giusi Cavezza
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Amos Adler
- Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Ioannis Pavleas
- Intensive Care Unit, Laikon General Hospital, Athens, Greece
| | - Rosa Zampino
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Roni Bitterman
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Hiba Zayyad
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Fidi Koppel
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Yael Zak-Doron
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Inbar Levi
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Adi Turjeman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Haim Ben-Zvi
- Clinical Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | | | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
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12
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Dickstein Y, Lellouche J, Ben Dalak Amar M, Schwartz D, Nutman A, Daitch V, Yahav D, Leibovici L, Skiada A, Antoniadou A, Daikos GL, Andini R, Zampino R, Durante-Mangoni E, Mouton JW, Friberg LE, Dishon Benattar Y, Bitterman R, Neuberger A, Carmeli Y, Paul M. Treatment Outcomes of Colistin- and Carbapenem-resistant Acinetobacter baumannii Infections: An Exploratory Subgroup Analysis of a Randomized Clinical Trial. Clin Infect Dis 2020; 69:769-776. [PMID: 30462182 DOI: 10.1093/cid/ciy988] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/15/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We evaluated the association between mortality and colistin resistance in Acinetobacter baumannii infections and the interaction with antibiotic therapy. METHODS This is a secondary analysis of a randomized controlled trial of patients with carbapenem-resistant gram-negative bacterial infections treated with colistin or colistin-meropenem combination. We evaluated patients with infection caused by carbapenem-resistant A. baumannii (CRAB) identified as colistin susceptible (CoS) at the time of treatment and compared patients in which the isolate was confirmed as CoS with those whose isolates were retrospectively identified as colistin resistant (CoR) when tested by broth microdilution (BMD). The primary outcome was 28-day mortality. RESULTS Data were available for 266 patients (214 CoS and 52 CoR isolates). Patients with CoR isolates had higher baseline functional capacity and lower rates of mechanical ventilation than patients with CoS isolates. All-cause 28-day mortality was 42.3% (22/52) among patients with CoR strains and 52.8% (113/214) among patients with CoS isolates (P = .174). After adjusting for variables associated with mortality, the mortality rate was lower among patients with CoR isolates (odds ratio [OR], 0.285 [95% confidence interval {CI}, .118-.686]). This difference was associated with treatment arm: Mortality rates among patients with CoR isolates were higher in those randomized to colistin-meropenem combination therapy compared to colistin monotherapy (OR, 3.065 [95% CI, 1.021-9.202]). CONCLUSIONS Colistin resistance determined by BMD was associated with lower mortality among patients with severe CRAB infections. Among patients with CoR isolates, colistin monotherapy was associated with a better outcome compared to colistin-meropenem combination therapy. CLINICAL TRIALS REGISTRATION NCT01732250.
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Affiliation(s)
- Yaakov Dickstein
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv
| | - Jonathan Lellouche
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center
| | - Maayan Ben Dalak Amar
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center
| | - David Schwartz
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center
| | - Amir Nutman
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv
| | - Vered Daitch
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv.,Department of Medicine E, Beilinson Hospital, Petah Tikva, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv.,Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv.,Department of Medicine E, Beilinson Hospital, Petah Tikva, Israel
| | - Anna Skiada
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Antoniadou
- National and Kapodistrian University of Athens, Athens, Greece.,Fourth Department of Medicine, Attikon University General Hospital, Athens, Greece
| | - George L Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Roberto Andini
- Department of Precision Medicine, University of Campania 'L Vanvitelli' and Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Napoli, Italy
| | - Rosa Zampino
- Department of Precision Medicine, University of Campania 'L Vanvitelli' and Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Napoli, Italy
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania 'L Vanvitelli' and Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Napoli, Italy
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Sweden
| | - Yael Dishon Benattar
- Institute of Infectious Diseases, Rambam Health Care Campus.,Cheryl Spencer Department of Nursing, University of Haifa
| | - Roni Bitterman
- Institute of Infectious Diseases, Rambam Health Care Campus
| | - Ami Neuberger
- Institute of Infectious Diseases, Rambam Health Care Campus
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv.,Molecular Epidemiology Laboratory, Tel-Aviv Sourasky Medical Center.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus.,Faculty of Medicine, Technion, Israel Institute of Technology, Haifa
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13
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Yahav D, Franceschini E, Koppel F, Turjeman A, Babich T, Bitterman R, Neuberger A, Ghanem-Zoubi N, Santoro A, Eliakim-Raz N, Pertzov B, Steinmetz T, Stern A, Dickstein Y, Maroun E, Zayyad H, Bishara J, Alon D, Edel Y, Goldberg E, Venturelli C, Mussini C, Leibovici L, Paul M. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis 2020; 69:1091-1098. [PMID: 30535100 DOI: 10.1093/cid/ciy1054] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [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: 10/01/2018] [Accepted: 12/07/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Gram-negative bacteremia is a major cause of morbidity and mortality in hospitalized patients. Data to guide the duration of antibiotic therapy are limited. METHODS This was a randomized, multicenter, open-label, noninferiority trial. Inpatients with gram-negative bacteremia, who were afebrile and hemodynamically stable for at least 48 hours, were randomized to receive 7 days (intervention) or 14 days (control) of covering antibiotic therapy. Patients with uncontrolled focus of infection were excluded. The primary outcome at 90 days was a composite of all-cause mortality; relapse, suppurative, or distant complications; and readmission or extended hospitalization (>14 days). The noninferiority margin was set at 10%. RESULTS We included 604 patients (306 intervention, 298 control) between January 2013 and August 2017 in 3 centers in Israel and Italy. The source of the infection was urinary in 411 of 604 patients (68%); causative pathogens were mainly Enterobacteriaceae (543/604 [90%]). A 7-day difference in the median duration of covering antibiotics was achieved. The primary outcome occurred in 140 of 306 patients (45.8%) in the 7-day group vs 144 of 298 (48.3%) in the 14-day group (risk difference, -2.6% [95% confidence interval, -10.5% to 5.3%]). No significant differences were observed in all other outcomes and adverse events, except for a shorter time to return to baseline functional status in the short-course therapy arm. CONCLUSIONS In patients hospitalized with gram-negative bacteremia achieving clinical stability before day 7, an antibiotic course of 7 days was noninferior to 14 days. Reducing antibiotic treatment for uncomplicated gram-negative bacteremia to 7 days is an important antibiotic stewardship intervention. CLINICAL TRIALS REGISTRATION NCT01737320.
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Adi Turjeman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Ami Neuberger
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
| | | | - Antonella Santoro
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Noa Eliakim-Raz
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Barak Pertzov
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Tali Steinmetz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | | | - Elias Maroun
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Danny Alon
- Department of Medicine B, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Claudia Venturelli
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
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14
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Dickstein Y, Leibovici L, Carmeli Y, Daikos G, Durante-Mangoni E, Friberg LE, Paul M. Reply to Wilson et al. Clin Infect Dis 2020; 71:1358-1359. [PMID: 31734694 DOI: 10.1093/cid/ciz1100] [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)
- Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yehuda Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel-Aviv, Israel
| | - George Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania 'L Vanvitelli' and Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Napoli, Italy
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Abstract
BackgroundIn 2012, Israel's National Center for Infection Control initiated a national stewardship programme that included mandatory annual reporting of antimicrobial use. Here we present nationwide Israeli data for the period 2012 to 2017.AimThe goal of this study was to detect trends in antimicrobial use in Israel following the introduction of the stewardship programme, as part of an assessment of the programme's impact.MethodsIn this retrospective observational study, data were collected from Israel's health maintenance organisations (HMOs), acute care hospitals and post-acute care hospitals (PACHs). Acute care hospital data were collected for general medical and surgical wards, and medical/surgical intensive care units (ICUs). Data were converted into defined daily doses (DDD), with use rates presented as DDD per 1,000 insured/day in the community and DDD per 100 patient-days in hospitals and PACHs. Trends were analysed using linear regression.ResultsAntimicrobial use decreased across sectors between 2012 and 2017. In the community, the decrease was modest, from 22.8 to 21.8 DDD per 1,000 insured per day (4.4%, p = 0.004). In acute care hospitals, antibiotic DDDs per 100 patient-days decreased from 100.0 to 84.0 (16.0%, p = 0.002) in medical wards, from 112.8 to 94.2 (16.5%, p = 0.004) in surgical wards and from 154.4 to 137.2 (11.1%, p = 0.04) in ICUs. Antimicrobial use decreased most markedly in PACHs, from 29.1 to 18.1 DDD per 100 patient-days (37.8%, p = 0.005).ConclusionBetween 2012 and 2017, antimicrobial use decreased significantly in all types of healthcare institutions in Israel, following the introduction of the nationwide antimicrobial stewardship programme.
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Affiliation(s)
- Yaakov Dickstein
- National Center for Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Elizabeth Temkin
- National Center for Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Debby Ben-David
- National Center for Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Yehuda Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,National Center for Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Mitchell J Schwaber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,National Center for Infection Control, Ministry of Health, Tel Aviv, Israel
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16
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Fallach N, Dickstein Y, Silberschein E, Turnidge J, Temkin E, Almagor J, Carmeli Y. Utilising sigmoid models to predict the spread of antimicrobial resistance at the country level. Euro Surveill 2020; 25:1900387. [PMID: 32553060 PMCID: PMC7403637 DOI: 10.2807/1560-7917.es.2020.25.23.1900387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 01/07/2020] [Indexed: 11/20/2022] Open
Abstract
BackgroundThe spread of antimicrobial resistance (AMR) is of worldwide concern. Public health policymakers and pharmaceutical companies pursuing antibiotic development require accurate predictions about the future spread of AMR.AimWe aimed to identify and model temporal and geographical patterns of AMR spread and to predict future trends based on a slow, intermediate or rapid rise in resistance.MethodsWe obtained data from five antibiotic resistance surveillance projects spanning the years 1997 to 2015. We aggregated the isolate-level or country-level data by country and year to produce country-bacterium-antibiotic class triads. We fitted both linear and sigmoid models to these triads and chose the one with the better fit. For triads that conformed to a sigmoid model, we classified AMR progression into one of three characterising paces: slow, intermediate or fast, based on the sigmoid slope. Within each pace category, average sigmoid models were calculated and validated.ResultsWe constructed a database with 51,670 country-year-bacterium-antibiotic observations, grouped into 7,440 country-bacterium-antibiotic triads. A total of 1,037 triads (14%) met the inclusion criteria. Of these, 326 (31.4%) followed a sigmoid (logistic) pattern over time. Among 107 triads for which both sigmoid and linear models could be fit, the sigmoid model was a better fit in 84%. The sigmoid model deviated from observed data by a median of 6.5%; the degree of deviation was related to the pace of spread.ConclusionWe present a novel method of describing and predicting the spread of antibiotic-resistant organisms.
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Affiliation(s)
- Noga Fallach
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yaakov Dickstein
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Erez Silberschein
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Elizabeth Temkin
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Jonatan Almagor
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Abdel Fattah M, Haquin J, Macgowan A, Grier S, Gibbs J, Chazan B, Yanovskay A, Ben Ami R, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Mauer S, Rodriguez-Bano J, Morales I, Oliver A, Ruiz De Gopegui E, Cano A, Machuca I, Gozalo-Marguello M, Martinez Martinez L, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Ceftazidime, Carbapenems, or Piperacillin-tazobactam as Single Definitive Therapy for Pseudomonas aeruginosa Bloodstream Infection: A Multisite Retrospective Study. Clin Infect Dis 2020; 70:2270-2280. [PMID: 31323088 DOI: 10.1093/cid/ciz668] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 01/16/2019] [Accepted: 07/16/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The optimal antibiotic regimen for Pseudomonas aeruginosa bacteremia is controversial. Although β-lactam monotherapy is common, data to guide the choice between antibiotics are scarce. We aimed to compare ceftazidime, carbapenems, and piperacillin-tazobactam as definitive monotherapy. METHODS A multinational retrospective study (9 countries, 25 centers) including 767 hospitalized patients with P. aeruginosa bacteremia treated with β-lactam monotherapy during 2009-2015. The primary outcome was 30-day all-cause mortality. Univariate and multivariate, including propensity-adjusted, analyses were conducted introducing monotherapy type as an independent variable. RESULTS Thirty-day mortality was 37/213 (17.4%), 42/210 (20%), and 55/344 (16%) in the ceftazidime, carbapenem, and piperacillin-tazobactam groups, respectively. Type of monotherapy was not significantly associated with mortality in either univariate, multivariate, or propensity-adjusted analyses (odds ratio [OR], 1.14; 95% confidence interval [CI], 0.52-2.46, for ceftazidime; OR, 1.3; 95% CI, 0.67-2.51, for piperacillin-tazobactam, with carbapenems as reference in propensity adjusted multivariate analysis; 542 patients). No significant difference between antibiotics was demonstrated for clinical failure, microbiological failure, or adverse events. Isolation of P. aeruginosa with new resistance to antipseudomonal drugs was significantly more frequent with carbapenems (36/206 [17.5%]) versus ceftazidime (25/201 [12.4%]) and piperacillin-tazobactam (28/332 [8.4%] (P = .007). CONCLUSIONS No significant difference in mortality, clinical, and microbiological outcomes or adverse events was demonstrated between ceftazidime, carbapenems, and piperacillin-tazobactam as definitive treatment of P. aeruginosa bacteremia. Higher rates of resistant P. aeruginosa after patients were treated with carbapenems, along with the general preference for carbapenem-sparing regimens, suggests using ceftazidime or piperacillin-tazobactam for treating susceptible infection.
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Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, and Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet, and Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- APEMAC, France
- CHRU-Nancy, Infectious Diseases Department, Université de Lorraine, France
| | - Manal Abdel Fattah
- CHRU-Nancy, Infectious Diseases Department, Université de Lorraine, France
| | - Justine Haquin
- CHRU-Nancy, Infectious Diseases Department, Université de Lorraine, France
| | - Alasdair Macgowan
- Department of Infection Sciences, Southmead Hospital, Bristol, United Kingdom
| | - Sally Grier
- Department of Infection Sciences, Southmead Hospital, Bristol, United Kingdom
| | - Julie Gibbs
- Department of Infection Sciences, Southmead Hospital, Bristol, United Kingdom
| | - Bibiana Chazan
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa
| | - Anna Yanovskay
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Israel
- Infectious Diseases Unit Sourasky Medical Center, Tel-Aviv
| | - Michal Landes
- Infectious Diseases Unit Sourasky Medical Center, Tel-Aviv
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | | | - Michael Buhl
- Division of Infectious Diseases, Tübingen University Hospital, Germany
| | - Susanna Mauer
- Division of Infectious Diseases, Tübingen University Hospital, Germany
| | - Jesus Rodriguez-Bano
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla
| | - Isabel Morales
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca
| | - Enrique Ruiz De Gopegui
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, University Hospital Marqués de Valdecilla-IDIVAL, Santander
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, University Hospital Marqués de Valdecilla-IDIVAL, Santander
| | | | | | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Faculty of Medicine, University of Ljubljana
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Faculty of Medicine, University of Ljubljana
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | | | - Virginie Vitrat
- Infectious Diseases Unit, Annecy-Genevois Hospital Center, Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa
| | | | | | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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18
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Nasser R, Rakedzon S, Dickstein Y, Mousa A, Solt I, Peterisel N, Feldman T, Neuberger A. Are all vaccines safe for the pregnant traveller? A systematic review and meta-analysis. J Travel Med 2020; 27:5588086. [PMID: 31616947 DOI: 10.1093/jtm/taz074] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 01/08/2023]
Abstract
Pregnant travellers and their offspring are vulnerable to severe outcomes following a wide range of infections. Vaccine-preventable diseases can have a particularly severe course in pregnant women, but little is known about the safety of travel vaccines in pregnant women. We performed a systematic review of all published literature concerning the safety of vaccines frequently given to travellers such as yellow fever, MMR (mumps, measles and rubella), influenza, Tdap (tetanus, diphtheria and pertussis), meningococcus, hepatitis A and B, rabies, polio, typhoid fever, tick-borne encephalitis and Japanese encephalitis vaccines. We included case series, cohort studies and randomized controlled trials (RCTs). For the meta-analysis, we included only RCTs that compared the administration of a vaccine to placebo or to no vaccine. Outcome measures included severe systemic adverse events, maternal outcomes related to the course of pregnancy, neonatal outcomes and local adverse events. We calculated the risk ratio and its 95% confidence interval as the summary measure. The safety of influenza vaccine is supported by high-quality evidence. For Tdap vaccine, no evidence of any harm was found in the meta-analysis of RCTs. A slight increase in chorioamnionitis rate was reported in 3 out of 12 observational studies. However, this small possible risk is far outweighed by a much larger benefit in terms of infant morbidity and mortality. Meningococcal vaccines are probably safe during pregnancy, as supported by RCTs comparing meningococcal vaccines to other vaccines. Data from observational studies support the safety of hepatitis A, hepatitis B and rabies vaccines, as well as that of the live attenuated yellow fever vaccine. We found little or no data about the safety of polio, typhoid, Japanese encephalitis, tick-borne encephalitis and MMR vaccines during pregnancy.
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Affiliation(s)
- Roni Nasser
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel
| | - Stav Rakedzon
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Amjad Mousa
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel
| | - Ido Solt
- The Rappaport's Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.,Department of Gynaecology and Obstetrics, Rambam Healthcare Campus, Haifa, Israel
| | - Neta Peterisel
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel.,Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Tzah Feldman
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel
| | - Ami Neuberger
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel.,Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,The Rappaport's Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
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19
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Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Fattah MA, Haquin J, MacGowan A, Grier S, Chazan B, Yanovskay A, Ami RB, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Maurer S, Rodriguez-Bano J, Morales I, Oliver A, de Gopegui ER, Cano A, Machuca I, Gozalo-Marguello M, Martinez-Martinez L, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Risk factors for mortality among patients with Pseudomonas aeruginosa bacteraemia: a retrospective multicentre study. Int J Antimicrob Agents 2020; 55:105847. [PMID: 31770625 DOI: 10.1016/j.ijantimicag.2019.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [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: 09/14/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 02/08/2023]
Abstract
This study aimed to evaluate risk factors for 30-day mortality among hospitalised patients with Pseudomonas aeruginosa bacteraemia, a highly fatal condition. A retrospective study was conducted between 1 January 2009 and 31 October 2015 in 25 centres (9 countries) including 2396 patients. Univariable and multivariable analyses of risk factors were conducted for the entire cohort and for patients surviving ≥48 h. A propensity score for predictors of appropriate empirical therapy was introduced into the analysis. Of the 2396 patients, 636 (26.5%) died within 30 days. Significant predictors (odds ratio and 95% confidence interval) of mortality in the multivariable analysis included patient-related factors: age (1.02, 1.01-1.03); female sex (1.34, 1.03-1.77); bedridden functional capacity (1.99, 1.24-3.21); recent hospitalisation (1.43, 1.07-1.92); concomitant corticosteroids (1.33, 1.02-1.73); and Charlson comorbidity index (1.05, 1.01-1.93). Infection-related factors were multidrug-resistant Pseudomonas (1.52, 1.15-2.1), non-urinary source (2.44, 1.54-3.85) and Sequential Organ Failure Assessment (SOFA) score (1.27, 1.18-1.36). Inappropriate empirical therapy was not associated with increased mortality (0.81, 0.49-1.33). Among 2135 patients surviving ≥48 h, hospital-acquired infection (1.59, 1.21-2.09), baseline endotracheal tube (1.63, 1.13-2.36) and ICU admission (1.53, 1.02-2.28) were additional risk factors. Risk factors for mortality among patients with P. aeruginosa were mostly irreversible. Early appropriate empirical therapy was not associated with reduced mortality. Further research should be conducted to explore subgroups that may not benefit from broad-spectrum antipseudomonal empirical therapy. Efforts should focus on prevention of infection, mainly hospital-acquired infection and multidrug-resistant pseudomonal infection.
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Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet and Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- Université de Lorraine, APEMAC, F-54000 Nancy, France; Université de Lorraine, CHRU de Nancy, Infectious Diseases Department, F-54000 Nancy, France
| | - Manal Abdel Fattah
- Université de Lorraine, CHRU de Nancy, Infectious Diseases Department, F-54000 Nancy, France
| | - Justine Haquin
- Université de Lorraine, CHRU de Nancy, Infectious Diseases Department, F-54000 Nancy, France
| | - Alasdair MacGowan
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Sally Grier
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Bibiana Chazan
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Anna Yanovskay
- Infectious Diseases Unit, Emek Medical Center, Afula, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Diseases Unit, Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Landes
- Infectious Diseases Unit, Sourasky Medical Center, Tel Aviv, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Evelina Tacconelli
- Division of Infectious Diseases, Tübingen University Hospital, Tübingen, Germany
| | - Michael Buhl
- Division of Infectious Diseases, Tübingen University Hospital, Tübingen, Germany
| | - Susanna Maurer
- Division of Infectious Diseases, Tübingen University Hospital, Tübingen, Germany
| | - Jesus Rodriguez-Bano
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Isabel Morales
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Antonio Oliver
- Servicio de Microbiología & Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Enrique Ruiz de Gopegui
- Servicio de Microbiología & Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, Córdoba, Spain
| | | | - Luis Martinez-Martinez
- Microbiology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Leonardo Pagani
- Infectious Diseases Unit, Annecy Genevois Hospital Center (CHANGE), Annecy, France
| | - Virginie Vitrat
- Infectious Diseases Unit, Annecy Genevois Hospital Center (CHANGE), Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, 39 Jabotinsky Road, Petah Tikva 49100, Israel.
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20
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Dickstein Y, Oster Y, Shimon O, Nesher L, Yahav D, Wiener-Well Y, Cohen R, Ben-Ami R, Weinberger M, Rahav G, Maor Y, Chowers M, Nir-Paz R, Paul M. Antibiotic treatment for invasive nonpregnancy-associated listeriosis and mortality: a retrospective cohort study. Eur J Clin Microbiol Infect Dis 2019; 38:2243-2251. [PMID: 31399915 DOI: 10.1007/s10096-019-03666-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 05/22/2019] [Accepted: 07/30/2019] [Indexed: 12/18/2022]
Abstract
Little evidence exists addressing the clinical value of adding gentamicin to ampicillin for invasive listeriosis. A multicenter retrospective observational study of nonpregnant adult patients with invasive listeriosis (primary bacteremia, central nervous system (CNS) disease, and others) in 11 hospitals in Israel between the years 2008 and 2014 was conducted. We evaluated the effect of penicillin-based monotherapy compared with early combination therapy with gentamicin, defined as treatment started within 48 h of culture results and continued for a minimum of 7 days. Patients who died within 48 h of the index culture were excluded. The primary outcome was 30-day all-cause mortality. A total of 190 patients with invasive listeriosis were included. Fifty-nine (30.6%) patients were treated with early combination therapy, 90 (46.6%) received monotherapy, and 44 (22.8%) received other treatments. Overall 30-day mortality was 20.5% (39/190). Factors associated with mortality included lower baseline functional status, congestive heart failure, and higher sequential organ failure assessment score. Source of infection, treatment type, and time from culture taken date to initiation of effective therapy were not associated with mortality. In multivariable analysis, monotherapy was not significantly associated with increased 30-day mortality compared with early combination therapy (OR 1.947, 95% CI 0.691-5.487). Results were similar in patients with CNS disease (OR 3.037, 95% CI 0.574-16.057) and primary bacteremia (OR 2.983, 95% CI 0.575-15.492). In our retrospective cohort, there was no statistically significant association between early combination therapy and 30-day mortality. A randomized controlled trial may be necessary to assess optimal treatment.
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Affiliation(s)
- Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, HaAliya HaShniya St. 8, 3109601, Haifa, Israel.
| | - Yonatan Oster
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Orit Shimon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yonit Wiener-Well
- Infectious Disease Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Regev Cohen
- Infectious Diseases Unit, Sanz Medical Center-Laniado Hospital, Netanya, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ronen Ben-Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Miriam Weinberger
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Galia Rahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Disease Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Yasmin Maor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Disease Unit, Wolfson Medical Center, Holon, Israel
| | - Michal Chowers
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Ran Nir-Paz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, HaAliya HaShniya St. 8, 3109601, Haifa, Israel. .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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21
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Dickstein Y, Temkin E, Ish Shalom M, Schwartz D, Carmeli Y, Schwaber MJ. Trends in antimicrobial resistance in Israel, 2014-2017. Antimicrob Resist Infect Control 2019; 8:96. [PMID: 31171967 PMCID: PMC6549337 DOI: 10.1186/s13756-019-0535-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 01/22/2019] [Accepted: 05/08/2019] [Indexed: 12/04/2022] Open
Abstract
We analyzed Israeli national data on antimicrobial susceptibility from bloodstream isolates collected between 2014 and 2017 and compared resistance proportions with those of Europe. The incidence of bloodstream infection (BSI) caused by most antibiotic-resistant organisms remained unchanged or decreased. An exception was increased incidence of BSI caused by third-generation cephalosporin-resistant Escherichia coli. Overall, resistance proportions were similar to those observed in southern Europe, with the exception of a lower proportion of carbapenem-resistant Klebsiella pneumoniae in Israel.
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Affiliation(s)
- Yaakov Dickstein
- 1National Center for Infection Control, Ministry of Health, Weizmann 6, 6423906 Tel Aviv, Israel
| | - Elizabeth Temkin
- 1National Center for Infection Control, Ministry of Health, Weizmann 6, 6423906 Tel Aviv, Israel
| | - Michal Ish Shalom
- 1National Center for Infection Control, Ministry of Health, Weizmann 6, 6423906 Tel Aviv, Israel
| | - David Schwartz
- 1National Center for Infection Control, Ministry of Health, Weizmann 6, 6423906 Tel Aviv, Israel
| | - Yehuda Carmeli
- 1National Center for Infection Control, Ministry of Health, Weizmann 6, 6423906 Tel Aviv, Israel.,2Sackler Faculty of Medicine, Tel Aviv University, Kalechkin 35, 6997801 Tel Aviv, Israel
| | - Mitchell J Schwaber
- 1National Center for Infection Control, Ministry of Health, Weizmann 6, 6423906 Tel Aviv, Israel.,2Sackler Faculty of Medicine, Tel Aviv University, Kalechkin 35, 6997801 Tel Aviv, Israel
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Paul M, Daikos GL, Durante-Mangoni E, Yahav D, Carmeli Y, Benattar YD, Skiada A, Andini R, Eliakim-Raz N, Nutman A, Zusman O, Antoniadou A, Pafundi PC, Adler A, Dickstein Y, Pavleas I, Zampino R, Daitch V, Bitterman R, Zayyad H, Koppel F, Levi I, Babich T, Friberg LE, Mouton JW, Theuretzbacher U, Leibovici L. Colistin alone versus colistin plus meropenem for treatment of severe infections caused by carbapenem-resistant Gram-negative bacteria: an open-label, randomised controlled trial. Lancet Infect Dis 2018; 18:391-400. [PMID: 29456043 DOI: 10.1016/s1473-3099(18)30099-9] [Citation(s) in RCA: 354] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/26/2017] [Accepted: 12/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colistin-carbapenem combinations are synergistic in vitro against carbapenem-resistant Gram-negative bacteria. We aimed to test whether combination therapy improves clinical outcomes for adults with infections caused by carbapenem-resistant or carbapenemase-producing Gram-negative bacteria. METHODS A randomised controlled superiority trial was done in six hospitals in Israel, Greece, and Italy. We included adults with bacteraemia, ventilator-associated pneumonia, hospital-acquired pneumonia, or urosepsis caused by carbapenem-non-susceptible Gram-negative bacteria. Patients were randomly assigned (1:1) centrally, by computer-generated permuted blocks stratified by centre, to intravenous colistin (9-million unit loading dose, followed by 4·5 million units twice per day) or colistin with meropenem (2-g prolonged infusion three times per day). The trial was open-label, with blinded outcome assessment. Treatment success was defined as survival, haemodynamic stability, improved or stable Sequential Organ Failure Assessment score, stable or improved ratio of partial pressure of arterial oxygen to fraction of expired oxygen for patients with pneumonia, and microbiological cure for patients with bacteraemia. The primary outcome was clinical failure, defined as not meeting all success criteria by intention-to-treat analysis, at 14 days after randomisation. This trial is registered at ClinicalTrials.gov, number NCT01732250, and is closed to accrual. FINDINGS Between Oct 1, 2013, and Dec 31, 2016, we randomly assigned 406 patients to the two treatment groups. Most patients had pneumonia or bacteraemia (355/406, 87%), and most infections were caused by Acinetobacter baumannii (312/406, 77%). No significant difference between colistin monotherapy (156/198, 79%) and combination therapy (152/208, 73%) was observed for clinical failure at 14 days after randomisation (risk difference -5·7%, 95% CI -13·9 to 2·4; risk ratio [RR] 0·93, 95% CI 0·83-1·03). Results were similar among patients with A baumannii infections (RR 0·97, 95% CI 0·87-1·09). Combination therapy increased the incidence of diarrhoea (56 [27%] vs 32 [16%] patients) and decreased the incidence of mild renal failure (37 [30%] of 124 vs 25 [20%] of 125 patients at risk of or with kidney injury). INTERPRETATION Combination therapy was not superior to monotherapy. The addition of meropenem to colistin did not improve clinical failure in severe A baumannii infections. The trial was unpowered to specifically address other bacteria. FUNDING EU AIDA grant Health-F3-2011-278348.
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Affiliation(s)
- Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - George L Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece; National and Kapodistrian University of Athens, Athens, Greece
| | - Emanuele Durante-Mangoni
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Napoli, Italy
| | - Dafna Yahav
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Yehuda Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel; Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Yael Dishon Benattar
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Anna Skiada
- First Department of Medicine, Laikon General Hospital, Athens, Greece; National and Kapodistrian University of Athens, Athens, Greece
| | - Roberto Andini
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Napoli, Italy
| | - Noa Eliakim-Raz
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Amir Nutman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel; Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Oren Zusman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Anastasia Antoniadou
- National and Kapodistrian University of Athens, Athens, Greece; Fourth Department of Medicine, Attikon University General Hospital, Athens, Greece
| | - Pia Clara Pafundi
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Napoli, Italy
| | - Amos Adler
- Microbiology Laboratory, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Ioannis Pavleas
- Intensive Care Unit, Laikon General Hospital, Athens, Greece
| | - Rosa Zampino
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Napoli, Italy
| | - Vered Daitch
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Roni Bitterman
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Hiba Zayyad
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Fidi Koppel
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Inbar Levi
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Tanya Babich
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands
| | | | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
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Beyar‐Katz O, Dickstein Y, Borok S, Vidal L, Leibovici L, Paul M. Empirical antibiotics targeting gram-positive bacteria for the treatment of febrile neutropenic patients with cancer. Cochrane Database Syst Rev 2017; 6:CD003914. [PMID: 28577308 PMCID: PMC6481386 DOI: 10.1002/14651858.cd003914.pub4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The pattern of infections among neutropenic patients with cancer has shifted in the last decades to a predominance of gram-positive infections. Some of these gram-positive bacteria are increasingly resistant to beta-lactams and necessitate specific antibiotic treatment. OBJECTIVES To assess the effectiveness of empirical anti-gram-positive (antiGP) antibiotic treatment for febrile neutropenic patients with cancer in terms of mortality and treatment failure. To assess the rate of resistance development, further infections and adverse events associated with additional antiGP treatment. SEARCH METHODS For the review update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2), MEDLINE (May 2012 to 2017), Embase (May 2012 to 2017), LILACS (2012 to 2017), conference proceedings, ClinicalTrials.gov trial registry, and the references of the included studies. We contacted the first authors of all included and potentially relevant trials. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing one antibiotic regimen versus the same regimen with the addition of an antiGP antibiotic for the treatment of febrile neutropenic patients with cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted all data. Risk ratios (RR) with 95% confidence intervals (CIs) were calculated. A random-effects model was used for all comparisons showing substantial heterogeneity (I2 > 50%). Outcomes were extracted by intention-to-treat and the analysis was patient-based whenever possible. MAIN RESULTS Fourteen trials and 2782 patients or episodes were included. Empirical antiGP antibiotics were tested at the onset of treatment in 12 studies, and for persistent fever in two studies. The antiGP treatment was a glycopeptide in nine trials. Eight studies were assessed in the overall mortality comparison and no significant difference was seen between the comparator arms, RR of 0.90 (95% CI 0.64 to 1.25; 8 studies, 1242 patients; moderate-quality data). Eleven trials assessed failure, including modifications as failures, while seven assessed overall failure disregarding treatment modifications. Failure with modifications was reduced, RR of 0.72 (95% CI 0.65 to 0.79; 11 studies, 2169 patients; very low-quality data), while overall failure was the same, RR of 1.00 (95% CI 0.79 to 1.27; 7 studies, 943 patients; low-quality data). Sensitivity analysis for allocation concealment and incomplete outcome data did not change the results. Failure among patients with gram-positive infections was reduced with antiGP treatment, RR of 0.56 (95% CI 0.38 to 0.84, 5 studies, 175 patients), although, mortality among these patients was not changed.Data regarding other patient subgroups likely to benefit from antiGP treatment were not available. Glycopeptides did not increase fungal superinfection rates and were associated with a reduction in documented gram-positive superinfections. Resistant colonisation was not documented in the studies. AUTHORS' CONCLUSIONS Based on very low- or low-quality evidence using the GRADE approach and overall low risk of bias, the current evidence shows that the empirical routine addition of antiGP treatment, namely glycopeptides, does not improve the outcomes of febrile neutropenic patients with cancer.
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Affiliation(s)
- Ofrat Beyar‐Katz
- Rambam Health Care CampusHematology and Bone Marrow TransplantationHaalyia St. 8HaifaIsrael3109601
| | - Yaakov Dickstein
- Tel Aviv Sourasky Medical CenterInfectious Diseases UnitTel AvivIsrael
| | - Sara Borok
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Liat Vidal
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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Dickstein Y, Nir-Paz R, Pulcini C, Cookson B, Beović B, Tacconelli E, Nathwani D, Vatcheva-Dobrevska R, Rodríguez-Baño J, Hell M, Saenz H, Leibovici L, Paul M. Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey. Clin Microbiol Infect 2016; 22:812.e9-812.e17. [PMID: 27373529 DOI: 10.1016/j.cmi.2016.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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: 01/25/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 10/24/2022]
Abstract
We aimed to assess the current status of infectious diseases (ID), clinical microbiology (CM) and infection control (IC) staffing in hospitals and to analyse modifiers of staffing levels. We conducted an Internet-based survey of European Society of Clinical Microbiology and Infectious Diseases members and affiliates, collecting data on hospital characteristics, ID management infrastructure, ID/IC-related activities and the ratio of physicians per 100 hospital beds. Regression analyses were conducted to examine factors associated with the physician-bed ratio. Five hundred sixty-seven hospital responses were collected between April and June 2015 from 61 countries, 81.2% (384/473) from Europe. A specialized inpatient ward for ID patients was reported in 58.4% (317/543) of hospitals. Rates of antibiotic stewardship programmes (ASP) and surveillance activities in survey hospitals were high, ranging from 88% to 90% for local antibiotic guidelines and 70% to 82% for programmes monitoring hospital-acquired infections. The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13). In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device-related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). Factors independently associated with higher ratios included compliance with European Union of Medical Specialists standards, smaller hospital size, tertiary-care institution, presence of a travel clinic, beds dedicated to ID and a CM unit. More than half of respondents estimated that additional staffing is needed for appropriate IC or ID management. No standard of physician staffing for ID/CM/IC in hospitals is available. A ratio of 1.21/100 beds will serve as an informed point of reference enabling ASP and infection surveillance.
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Affiliation(s)
- Y Dickstein
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - R Nir-Paz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - C Pulcini
- Université de Lorraine, Université Paris Descartes, EA 4360 APEMAC and CHU de Nancy, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - B Cookson
- Division of Infection and Immunity, University College London, Gower Street, London, United Kingdom
| | - B Beović
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia
| | - E Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, DZIF Center, Tübingen University Hospital, Tübingen, Germany
| | - D Nathwani
- Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - R Vatcheva-Dobrevska
- Department of Microbiology and Virology, University Hospital Queen Joanna, Sofia, Bulgaria
| | - J Rodríguez-Baño
- Unidad Clínica Intercentros de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Seville, Spain; Departamento de Medicina, Universidad de Sevilla, Seville, Spain
| | - M Hell
- Department of Hospital Epidemiology and Infection Control, University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - H Saenz
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Basel, Switzerland
| | - L Leibovici
- Medicine E, Rabin Medical Centre, Beilinson Hospital, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - M Paul
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine-Technion, Israel Institute of Technology, Haifa, Israel.
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Paul M, Dickstein Y, Raz-Pasteur A. Antibiotic de-escalation for bloodstream infections and pneumonia: systematic review and meta-analysis. Clin Microbiol Infect 2016; 22:960-967. [PMID: 27283148 DOI: 10.1016/j.cmi.2016.05.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [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: 03/07/2016] [Revised: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 12/29/2022]
Abstract
Antibiotic de-escalation is an appealing strategy in antibiotic stewardship programmes. We aimed to assess its safety and effects using a systematic review and meta-analysis. We included randomized controlled trials (RCTs) and observational studies assessing adults with bacteraemia, microbiologically documented pneumonia or severe sepsis, comparing between antibiotic de-escalation and no de-escalation. De-escalation was defined as changing an initially covering antibiotic regimen to a narrower spectrum regimen based on antibiotic susceptibility testing results within 96 hours. The primary outcome was 30-day all-cause mortality. A search of published articles and conference proceedings was last updated in September 2015. Crude and adjusted ORs with 95% CI were pooled in random-effects meta-analyses. Sixteen observational studies and three RCTs were included. Risk of bias related to confounding was high in the observational studies. De-escalation was associated with fewer deaths in the unadjusted analysis (OR 0.53, 95% CI 0.39-0.73), 19 studies, moderate heterogeneity. In the adjusted analysis there was no significant difference in mortality (adjusted OR 0.83, 95% CI 0.59-1.16), 11 studies, moderate heterogeneity and the RCTs showed non-significant increased mortality with de-escalation (OR 1.73, 95% 0.97-3.06), three trials, no heterogeneity. There was a significant unadjusted association between de-escalation and survival in bacteraemia/severe sepsis (OR 0.45, 95% CI 0.30-0.67) and ventilator-associated pneumonia (OR 0.49, 95% CI 0.26-0.95), but not with other pneumonia (OR 0.97, 95% CI 0.45-2.12). Only two studies reported on the emergence of resistance with inconsistent findings. Observational studies suggest lower mortality with antibiotic susceptibility testing-based de-escalation for bacteraemia, severe sepsis and ventilator-associated pneumonia that was not demonstrated in RCTs.
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Affiliation(s)
- M Paul
- Infectious Diseases Institute, Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Y Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - A Raz-Pasteur
- Infectious Diseases Institute, Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Medicine A, Rambam Health Care Campus, Haifa, Israel
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26
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Dickstein Y, Edelman R, Dror T, Hussein K, Bar-Lavie Y, Paul M. Carbapenem-resistant Enterobacteriaceae colonization and infection in critically ill patients: a retrospective matched cohort comparison with non-carriers. J Hosp Infect 2016; 94:54-9. [PMID: 27392978 DOI: 10.1016/j.jhin.2016.05.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [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: 02/18/2016] [Accepted: 05/31/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine whether carbapenem-resistant Enterobacteriaceae (CRE) carriage is associated with incidence of clinical infection as a means of assessing whether the morbidity and mortality associated with these bacteria are mediated by underlying conditions or intrinsic properties of CRE. METHODS This retrospective matched cohort study compared the incidence of invasive infections in CRE-colonized patients and matched non-carriers in the intensive care unit (ICU). The primary outcome was infection caused by CRE of the same species as the colonizing strain among CRE carriers, and infections caused by carbapenem-sensitive strains of the same organism in non-carriers. Hospital discharge and death were considered as competing events. Competing-risks hazard analysis was performed for the entire cohort and for a nested cohort matched by Acute Physiology and Chronic Health Evaluation (APACHE) II scores, stratified by matching. RESULTS In total, 146 CRE carriers were compared with 292 non-carriers. Patients were well matched for most risk factors for Enterobacteriaceae infection, including age, renal failure, previous invasive infection, previous hospitalization, APACHE II score, length of mechanical ventilation, length of hospitalization and CRE carriage. On regression analysis, colonization with CRE was independently associated with Enterobacteriaceae infection {cause-specific hazard ratio (CSHR) 2.06 [95% confidence interval (CI) 1.03-4.09]}. On regression analysis of the APACHE-II-matched cohort (N=284), colonization with CRE remained significantly associated with Enterobacteriaceae infection [CSHR 3.32 (95% CI 1.31-8.43)]. CONCLUSIONS Colonization with CRE was associated with at least a two-fold increased risk of infection by the colonizing strain amongst ICU patients.
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Affiliation(s)
- Y Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - R Edelman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - T Dror
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - K Hussein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Y Bar-Lavie
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Department of Intensive Care, Rambam Health Care Campus, Haifa, Israel
| | - M Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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27
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Dickstein Y, Leibovici L, Yahav D, Eliakim-Raz N, Daikos GL, Skiada A, Antoniadou A, Carmeli Y, Nutman A, Levi I, Adler A, Durante-Mangoni E, Andini R, Cavezza G, Mouton JW, Wijma RA, Theuretzbacher U, Friberg LE, Kristoffersson AN, Zusman O, Koppel F, Dishon Benattar Y, Altunin S, Paul M. Multicentre open-label randomised controlled trial to compare colistin alone with colistin plus meropenem for the treatment of severe infections caused by carbapenem-resistant Gram-negative infections (AIDA): a study protocol. BMJ Open 2016; 6:e009956. [PMID: 27098822 PMCID: PMC4838684 DOI: 10.1136/bmjopen-2015-009956] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The emergence of antibiotic-resistant bacteria has driven renewed interest in older antibacterials, including colistin. Previous studies have shown that colistin is less effective and more toxic than modern antibiotics. In vitro synergy studies and clinical observational studies suggest a benefit of combining colistin with a carbapenem. A randomised controlled study is necessary for clarification. METHODS AND ANALYSIS This is a multicentre, investigator-initiated, open-label, randomised controlled superiority 1:1 study comparing colistin monotherapy with colistin-meropenem combination therapy for infections caused by carbapenem-resistant Gram-negative bacteria. The study is being conducted in 6 centres in 3 countries (Italy, Greece and Israel). We include patients with hospital-associated and ventilator-associated pneumonia, bloodstream infections and urosepsis. The primary outcome is treatment success at day 14, defined as survival, haemodynamic stability, stable or improved respiratory status for patients with pneumonia, microbiological cure for patients with bacteraemia and stability or improvement of the Sequential Organ Failure Assessment (SOFA) score. Secondary outcomes include 14-day and 28-day mortality as well as other clinical end points and safety outcomes. A sample size of 360 patients was calculated on the basis of an absolute improvement in clinical success of 15% with combination therapy. Outcomes will be assessed by intention to treat. Serum colistin samples are obtained from all patients to obtain population pharmacokinetic models. Microbiological sampling includes weekly surveillance samples with analysis of resistance mechanisms and synergy. An observational trial is evaluating patients who met eligibility requirements but were not randomised in order to assess generalisability of findings. ETHICS AND DISSEMINATION The study was approved by ethics committees at each centre and informed consent will be obtained for all patients. The trial is being performed under the auspices of an independent data and safety monitoring committee and is included in a broad dissemination strategy regarding revival of old antibiotics. TRIAL REGISTRATION NUMBER NCT01732250 and 2012-004819-31; Pre-results.
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Affiliation(s)
- Yaakov Dickstein
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Noa Eliakim-Raz
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - George L Daikos
- First Department of Medicine, University of Athens, Athens, Greece
| | - Anna Skiada
- First Department of Medicine, University of Athens, Athens, Greece
| | | | - Yehuda Carmeli
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Amir Nutman
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Inbar Levi
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Amos Adler
- Microbiology Laboratory, Tel Aviv Sourasky Medical Centre, Tel-Aviv, Israel
| | | | - Roberto Andini
- Internal Medicine, Second University of Naples, Monaldi Hospital-AORN dei Colli, Napoli, Italy
| | - Giusi Cavezza
- Internal Medicine, Second University of Naples, Monaldi Hospital-AORN dei Colli, Napoli, Italy
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
- Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
| | - Rixt A Wijma
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | | | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | - Oren Zusman
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Fidi Koppel
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | | | - Sergey Altunin
- Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Mical Paul
- Division of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
- Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Magen E, Waitman DA, Goldstein N, Schlesinger M, Dickstein Y, Kahan NR. Helicobacter pylori infection in patients with selective immunoglobulin a deficiency. Clin Exp Immunol 2016; 184:332-7. [PMID: 26749258 DOI: 10.1111/cei.12765] [Citation(s) in RCA: 8] [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: 11/16/2015] [Revised: 12/12/2015] [Accepted: 12/14/2015] [Indexed: 12/24/2022] Open
Abstract
Selective immunoglobulin A (IgA) deficiency (IgAD) is the most common primary immunodeficiency in the western world. The aim of the study was to investigate the prevalence and clinical characteristics of Helicobacter pylori-infected dyspeptic patients with IgAD. Case samples were drawn from all subjects ≥ 12 years of age (n = 104729) who had undergone serum total IgA measurements during 2004-14 for any reason at Leumit Healthcare Services (Israel) and had serum total IgA < 0·07 g/l. The control group was comprised of a random sample of remaining patients with a case-control ratio of 10 controls for each case. The dyspeptic diseases were identified and retrieved from Leumit Health Care Services electronic database using specific ICD-9-CM diagnostic codes. The case group included 347 subjects and the control group 3470 subjects. There were no significant differences in the prevalence of patients with dyspepsia [84 (24·2%) versus 821 (23·6%) for cases and controls, respectively]. Additionally, there was no difference in a proportion of dyspeptic H. pylori-positive subjects [59 (17·1%) versus 524 (15·1%)] between the case and control groups. Only 59 (17%) among the 347 IgAD patients underwent gastroscopy. A significantly larger proportion of case subjects experienced several forms of gastritis [13 (61·9%) versus 38 (21·6%), P < 0·001), duodenal ulcers [seven (33·3%) versus 19 (10·8%); P = 0·01] and nodular lymphoid hyperplasia (NLH) [two (9·5%) versus none; P = 0·011]. IgAD is not associated with increased prevalence of H. pylori-associated dyspepsia; nevertheless, H. pylori-infected dyspeptic IgAD subjects experience more EGD-proved gastritis, duodenal ulcers and NLH.
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Affiliation(s)
- E Magen
- Leumit Health Services, Ashdod, Israel.,Clinical Immunology and Allergy Unit, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | | | - N Goldstein
- Clinical Immunology and Allergy Unit, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | - M Schlesinger
- Clinical Immunology and Allergy Unit, Barzilai University Medical Center, Ben Gurion University of the Negev, Ashkelon, Israel
| | | | - N R Kahan
- Leumit Health Services, Ashdod, Israel.,School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Dror T, Dickstein Y, Dubourg G, Paul M. Microbiota manipulation for weight change. Microb Pathog 2016; 106:146-161. [PMID: 26792677 DOI: 10.1016/j.micpath.2016.01.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 12/21/2022]
Abstract
Manipulation of the intestinal microbiota has been linked to weight changes and obesity. To explore the influence of specific agents that alter the intestinal flora on weight in different patient groups we conducted a meta-analysis of randomized controlled trials (RCTs) reporting on the effects of probiotics, prebiotics, synbiotics, and antibiotics on weight. We searched the Pubmed and Cochrane Library databases for trials on adults, children, and infants evaluating the effects of these substances on weight. Our primary outcome was weight change from baseline. Standardized mean differences (SMDs) with 95% confidence intervals were calculated. We identified and included 13 adult, 17 children, and 23 infant RCTs. Effects were opposite among adults and children, showing weight loss among adults (SMD -0.54 [-0.83, -0.25)) and minor weight gains among children (SMD 0.20 [0.04, 0.36]) and infants (SMD 0.30 [-0.01, 0.62]) taking mainly Lactobacillus probiotic supplements. Heterogeneity was substantial in the adult and infant analyses and could not be explained by intervention or patient characteristics. Azithromycin administration in children with pulmonary disease was associated with weight gain (SMD 0.39 [0.24, 0.54]), without heterogeneity. A high risk of selective reporting and attrition bias was detected across the studies, making it difficult to draw firm conclusions. Overall, our meta-analysis suggests that there may be a role for probiotics in promoting weight loss in adults and weight gain in children, however additional studies are needed. Though we cannot recommend antibiotic administration for weight manipulation, its use provides advantageous weight gain in children with cystic fibrosis and bronchiectasis.
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Affiliation(s)
- Tal Dror
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Grégory Dubourg
- Pôle des Maladies Infectieuses et Tropicales Clinique et Biologique, Fédération de Bactériologie-Hygiène-Virologie, University, Hospital Centre Timone, Institut Hospitalo-Universitaire (IHU) Méditerranée Infection, Assistance Publique - Hôpitaux de Marseille, Marseille, France; Université Aix-Marseille, Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE) UM 63 CNRS 7278 IRD 198 INSERM U1095, Facultés de Médecine et de Pharmacie, Marseille, France
| | - Mical Paul
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.
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Paul M, Bishara J, Yahav D, Goldberg E, Neuberger A, Ghanem-Zoubi N, Dickstein Y, Nseir W, Dan M, Leibovici L. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin resistant Staphylococcus aureus: randomised controlled trial. BMJ 2015; 350:h2219. [PMID: 25977146 PMCID: PMC4431679 DOI: 10.1136/bmj.h2219] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To show non-inferiority of trimethoprim-sulfamethoxazole compared with vancomycin for the treatment of severe infections due to meticillin resistant Staphylococcus aureus (MRSA). DESIGN Parallel, open label, randomised controlled trial. SETTING Four acute care hospitals in Israel. PARTICIPANTS Adults with severe infections caused by MRSA susceptible to trimethoprim-sulfamethoxazole and vancomycin. Patients with left sided endocarditis, meningitis, chronic haemodialysis, and prolonged neutropenia were excluded. INTERVENTIONS Trimethoprim-sulfamethoxazole 320 mg/1600 mg twice daily versus vancomycin 1 g twice daily for a minimum of seven days and then by indication. MAIN OUTCOME MEASURES The primary efficacy outcome was treatment failure assessed at day 7, consisting of death, persistence of haemodynamic instability or fever, stable or worsening Sequential Organ Failure Assessment score, and persistence of bacteraemia. The primary safety outcome was all cause mortality at day 30. Non-inferiority was defined by a difference of less than 15% for treatment failure. RESULTS 252 patients were included in the trial, of whom 91 (36%) had bacteraemia. No significant difference in treatment failure was seen for trimethoprim-sulfamethoxazole (51/135, 38%) versus vancomycin (32/117, 27%)-risk ratio 1.38 (95% confidence interval 0.96 to 1.99). However, trimethoprim-sulfamethoxazole did not meet the non-inferiority criterion-absolute difference 10.4% (95% confidence interval -1.2% to 21.5%). For patients with bacteraemia, the risk ratio was 1.40 (0.91 to 2.16). In a multivariable logistic regression analysis, trimethoprim-sulfamethoxazole was significantly associated with treatment failure (adjusted odds ratio 2.00, 1.09 to 3.65). The 30 day mortality rate was 32/252 (13%), with no significant difference between arms. Among patients with bacteraemia, 14/41 (34%) treated with trimethoprim-sulfamethoxazole and 9/50 (18%) with vancomycin died (risk ratio 1.90, 0.92 to 3.93). CONCLUSIONS High dose trimethoprim-sulfamethoxazole did not achieve non-inferiority to vancomycin in the treatment of severe MRSA infections. The difference was particularly marked for patients with bacteraemia. Trial registration Clinical trials NCT00427076.
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Affiliation(s)
- Mical Paul
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Jihad Bishara
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Elad Goldberg
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Ami Neuberger
- Division of Infectious Diseases, Medicine B, Rambam Health Care Campus, Haifa, Israel Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine, Haifa
| | | | - Yaakov Dickstein
- Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine, Haifa Division of Infectious Diseases, Medicine A, Rambam Health Care Campus, Haifa
| | - William Nseir
- Internal Medicine Department, Holy Family Hospital, Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan Univesity, Safed, Israel
| | - Michael Dan
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Infectious Diseases Unit, E Wolfson Hospital, Holon, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
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Hussein K, Savin Z, Shani L, Dickstein Y, Geffen Y, Raz-Pasteur A. Infective endocarditis caused by Finegoldia magna following aortic dissection repair: a case report and data evaluation. Am J Case Rep 2014; 15:554-8. [PMID: 25515374 PMCID: PMC4270072 DOI: 10.12659/ajcr.892057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [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: 11/25/2022]
Abstract
Patient: Male, 45 Final Diagnosis: Endocarditis Symptoms: — Medication: — Clinical Procedure: Antibiotic treatment and aortic repair Specialty: Surgery
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Affiliation(s)
- Khetam Hussein
- Infectious Disease Unit, Rambam Health Care Campus, Haifa, Israel
| | - Ziv Savin
- Department of Internal Medicine A, Rambam Health Care Campus, Haifa, Israel
| | - Liran Shani
- Department of Internal Medicine A, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Department of Internal Medicine A, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- Laboratory of Microbiology, Rambam Health Care Campus, Haifa, Israel
| | - Ayelet Raz-Pasteur
- Department of Internal Medicine A, Rambam Health Care Campus, Haifa, Israel
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Dickstein Y, Neuberger A, Golus M, Schwartz E. Epidemiologic profile of patients seen in primary care clinics in an urban and a rural setting in Haiti, 2010-11. Int Health 2014; 6:258-62. [PMID: 24969645 DOI: 10.1093/inthealth/ihu033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 11/13/2022] Open
Abstract
BACKGROUND This study examined the demographic and epidemiological differences between patient populations presenting to a rural and an urban clinic in Haiti. METHODS A primary health clinic was established in urban Leogane, and a once-weekly clinic was established in Magandou, a rural village. Patient data were recorded for all individuals presenting to each clinic. RESULTS Over 7 months, 6632 patients (median age 25) were seen in the urban clinic, and 567 (median age 47) in the rural clinic. There was a female majority at both sites. Hypertension was diagnosed in 41.9% (238/567) of the rural population over 40 years of age, while 29.5% (1956/6632) of patients in the urban setting had the same diagnosis (p<0.001). Among women of reproductive age, 20.4% (1353/6632) were diagnosed with STDs in the urban setting versus 8.6% (49/567) at the rural clinic (p=0.004). Eighty-eight patients at the urban clinic had a vector-borne disease, while none were diagnosed among the rural population. CONCLUSIONS Screening and treatment of hypertension in Haiti must address the wide rural prevalence. STDs are a major urban health issue requiring treatment for both patients and their partners. Vector-borne disease was unseen in the rural clinic, despite an altitude insufficient to prevent mosquito-borne illness.
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Affiliation(s)
- Yaakov Dickstein
- Internal Medicine Department A, Rambam Medical Center, Ha'Aliya 6, Haifa, Israel, 31096
| | - Ami Neuberger
- Infectious Disease Unit, Rambam Medical Center, Ha'Aliya 6, Haifa, Israel, 31096 Internal Medicine Department B, Rambam Medical Center, Ha'Aliya 6, Haifa, Israel, 31096
| | - Miri Golus
- Intensive Care Unit, Rambam Medical Center, Ha'Aliya 6, Haifa, Israel, 31096
| | - Eli Schwartz
- The Center for Geographic Medicine and Department of Medicine C, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Neuberger A, Meltzer E, Leshem E, Dickstein Y, Stienlauf S, Schwartz E. The changing epidemiology of human African trypanosomiasis among patients from nonendemic countries--1902-2012. PLoS One 2014; 9:e88647. [PMID: 24586363 PMCID: PMC3929605 DOI: 10.1371/journal.pone.0088647] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/07/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although human African trypanosomiasis (HAT) is uncommon among patients from non-endemic countries (NEC), there has been an increase in the number of cases reported in recent years. METHODS A systematic review of the literature was performed. The number of incoming tourists to HAT endemic countries was obtained from the United Nations World Tourism Organization. All HAT cases diagnosed in patients from NEC were included. Immigrants and refugees were excluded. We compared patients during and after the colonial period, and analyzed the relationship between the number of incoming travellers and the number of HAT cases. RESULTS Between 1902 and 2012, HAT was reported in 244 patients. Most HAT cases were reported before 1920, and after the year 2000. In the colonial era the average age of patients was lower (32.5±7.8 vs. 43.0±16.1 years, P<0.001), the proportion of females was lower (10.0% vs. 23.9%, P<0.01], most cases were diagnosed in expatriates, missionaries and soldiers (74.3%), and Gambian trypanosomiasis accounted for 86/110, (78%) of cases. In the post-colonial era most patients 91/125 (72.8%) were short-term tourists to game parks in Eastern and South-Eastern Africa (mainly in Tanzania); Rhodesian trypanosomiasis accounted for 94/123 (76.4%) of cases. Between 1995 and 2010 there has been a constant linear increase in the number of incoming tourists to Tanzania, and HAT cases occurred in small outbreaks rather than following a similar linear pattern. CONCLUSIONS In recent decades HAT patients from NEC are older, and more likely to be tourists who acquired the disease while visiting game-parks in Eastern and South-Eastern Africa. While Rhodesian trypanosomiasis is relatively uncommon among Africans, it now accounts for most cases reported among patients from NEC. Returning febrile travellers without an alternative diagnosis should be evaluated for HAT. Cases among travellers may serve as sentinels for Rhodesian trypanosomiasis "hot spots" in Africa.
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Affiliation(s)
- Ami Neuberger
- Unit of Infectious Diseases and Internal Medicine B, Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Eyal Meltzer
- The Center for Geographic Medicine and Internal Medicine A and C, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Leshem
- The Center for Geographic Medicine and Internal Medicine A and C, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Shmuel Stienlauf
- The Center for Geographic Medicine and Internal Medicine A and C, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Schwartz
- The Center for Geographic Medicine and Internal Medicine A and C, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Paul M, Dickstein Y, Borok S, Vidal L, Leibovici L. Empirical antibiotics targeting Gram-positive bacteria for the treatment of febrile neutropenic patients with cancer. Cochrane Database Syst Rev 2014:CD003914. [PMID: 24425445 DOI: 10.1002/14651858.cd003914.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [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: 11/08/2022]
Abstract
BACKGROUND The pattern of infections among neutropenic cancer patients has shifted in the last decades to a predominance of Gram-positive infections. Some of these Gram-positive bacteria are increasingly resistant to beta-lactams and necessitate specific antibiotic treatment. OBJECTIVES To assess the effectiveness of empirical antiGram-positive (antiGP) antibiotic treatment for febrile neutropenic cancer patients in terms of mortality and treatment failure. To assess the rate of resistance development, further infections and adverse events associated with additional antiGP treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 7), MEDLINE (1966 to 2013), EMBASE (1982 to 2013), LILACS (1982 to 2013), conference proceedings, and the references of the included studies. First authors of all included and potentially relevant trials were contacted. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing one antibiotic regimen to the same regimen with the addition of an antiGP antibiotic for the treatment of febrile neutropenic cancer patients. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias, and extracted all data. Risk ratios (RR) with 95% confidence intervals (CI) were calculated. A random-effects model was used for all comparisons showing substantial heterogeneity (I(2) > 50%). Outcomes were extracted by intention to treat and the analysis was patient-based whenever possible. MAIN RESULTS Thirteen trials and 2392 patients or episodes were included. Empirical antiGP antibiotics were tested at the onset of treatment in 11 studies, and for persistent fever in two studies. The antiGP treatment was a glycopeptide in nine trials. Seven studies were assessed in the overall mortality comparison and no significant difference was seen between the comparator arms, RR of 0.82 (95% CI 0.56 to 1.20, 852 patients). Ten trials assessed failure, including modifications as failures, while six assessed overall failure disregarding treatment modifications. Failure with modifications was significantly reduced, RR of 0.76 (95% CI 0.68 to 0.85, 1779 patients) while overall failure was the same, RR of 1.00 (95% CI 0.79 to 1.27, 943 patients). Sensitivity analysis for allocation concealment and incomplete outcome data did not change the results. Both mortality and failure did not differ significantly among patients with Gram-positive infections, but the number of studies in the comparisons was small. Data regarding other patient subgroups likely to benefit from antiGP treatment were not available. Glycopeptides did not increase fungal superinfection rates and were associated with a reduction in documented Gram-positive superinfections. Resistant colonisation was not documented in the studies. AUTHORS' CONCLUSIONS Current evidence shows that the empirical routine addition of antiGP treatment, namely glycopeptides, does not improve the outcomes of febrile neutropenic patients with cancer.
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Affiliation(s)
- Mical Paul
- Unit of Infectious Diseases, Rambam Health Care Center, Haifa, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 49100
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Paul M, Dickstein Y, Schlesinger A, Grozinsky-Glasberg S, Soares-Weiser K, Leibovici L. Beta-lactam versus beta-lactam-aminoglycoside combination therapy in cancer patients with neutropenia. Cochrane Database Syst Rev 2013; 2013:CD003038. [PMID: 23813455 PMCID: PMC6457814 DOI: 10.1002/14651858.cd003038.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [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: 02/04/2023]
Abstract
BACKGROUND Continued controversy surrounds the optimal empirical treatment for febrile neutropenia. New broad-spectrum beta-lactams have been introduced as single treatment, and classically, a combination of a beta-lactam with an aminoglycoside has been used. OBJECTIVES To compare beta-lactam monotherapy versus beta-lactam-aminoglycoside combination therapy for cancer patients with fever and neutropenia. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 7, 2012), LILACS (August 2012), MEDLINE and EMBASE (August 2012) and the Database of Abstracts of Reviews of Effects (DARE) (Issue 3, 2012). We scanned references of all included studies and pertinent reviews and contacted the first author of each included trial, as well as the pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing any beta-lactam antibiotic monotherapy with any combination of a beta-lactam and an aminoglycoside antibiotic, for the initial empirical treatment of febrile neutropenic cancer patients. All cause mortality was the primary outcome assessed. DATA COLLECTION AND ANALYSIS Data concerning all cause mortality, infection related mortality, treatment failure (including treatment modifications), super-infections, adverse effects and study quality measures were extracted independently by two review authors. Risk ratios (RRs) with their 95% confidence intervals (CIs) were estimated. Outcomes were extracted by intention-to-treat (ITT) analysis whenever possible. Individual domains of risk of bias were examined through sensitivity analyses. Published data were complemented by correspondence with authors. MAIN RESULTS Seventy-one trials published between 1983 and 2012 were included. All cause mortality was lower with monotherapy (RR 0.87, 95% CI 0.75 to 1.02, without statistical significance). Results were similar for trials comparing the same beta-lactam in both trial arms (11 trials, 1718 episodes; RR 0.74, 95% CI 0.53 to 1.06) and for trials comparing different beta-lactams-usually a broad-spectrum beta-lactam compared with a narrower-spectrum beta-lactam combined with an aminoglycoside (33 trials, 5468 episodes; RR 0.91, 95% CI 0.77 to 1.09). Infection related mortality was significantly lower with monotherapy (RR 0.80, 95% CI 0.64 to 0.99). Treatment failure was significantly more frequent with monotherapy in trials comparing the same beta-lactam (16 trials, 2833 episodes; RR 1.11, 95% CI 1.02 to 1.20), and was significantly more frequent with combination therapy in trials comparing different beta-lactams (55 trials, 7736 episodes; RR 0.92, 95% CI 0.88 to 0.97). Bacterial super-infections occurred with equal frequency, and fungal super-infections were more common with combination therapy. Adverse events were more frequent with combination therapy (numbers needed to harm 4; 95% CI 4 to 5). Specifically, the difference with regard to nephrotoxicity was highly significant. Adequate trial methods were associated with a larger effect estimate for mortality and smaller effect estimates for failure. Nearly all trials were open-label. No correlation was noted between mortality and failure rates and these trials. AUTHORS' CONCLUSIONS Beta-lactam monotherapy is advantageous compared with beta-lactam-aminoglycoside combination therapy with regard to survival, adverse events and fungal super-infections. Treatment failure should not be regarded as the primary outcome in open-label trials, as it reflects mainly treatment modifications.
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Affiliation(s)
- Mical Paul
- Unit of Infectious Diseases, Rambam Health Care Center. Haifa, Israel and Sackler Faculty of Medicine, Tel Aviv, Israel.
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Revello MG, Vauloup-Fellous C, Grangeot-Keros L, van Helden J, Dickstein Y, Lipkin I, Mühlbacher A, Lazzarotto T. Clinical evaluation of new automated cytomegalovirus IgM and IgG assays for the Elecsys(®) analyser platform. Eur J Clin Microbiol Infect Dis 2012; 31:3331-9. [PMID: 22850741 DOI: 10.1007/s10096-012-1700-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
Cytomegalovirus (CMV) is a leading cause of physical and neurological abnormalities in newborns. Hence, the diagnosis of CMV infection in pregnant women is necessary in order to allow appropriate management of their pregnancy. New assays have been developed for the Roche Elecsys® immunoassay platform that detect CMV-specific immunoglobulin (Ig)M and IgG, with the IgM assay designed to target IgM produced at the start of infection rather than IgM persisting later in infection. This study aimed to evaluate the performance of the new assays compared with other commercial kits widely distributed in laboratories. The performance of the Elecsys and comparator CMV IgM and IgG assays was assessed using 967 preselected patient samples characterised by CMV infection status, as well as being compared using 1,668 unselected clinical samples. The Elecsys CMV IgM and IgG assays performed consistently with comparator assays using the preselected samples. The Elecsys CMV IgM assay showed improved sensitivity compared with the Enzygnost® assay in primary infection (91.2 % vs. 79.4 %) and improved specificity over the Architect® assay in potentially cross-reacting samples (94.1 % vs. 82.4 %). The Elecsys IgM assay reported fewer positive results in the later stages of CMV infection compared with ETI-CYTOK-M ELISA, while the Elecsys IgG assay reported slightly fewer negative results in the early stages of infection compared with ETI-CYTOK-G ELISA. There was good agreement between Elecsys and comparator assays using unselected clinical samples (range 90.4-99.4 %). The Elecsys CMV IgM and IgG assays compare well with routinely used assays and are suitable for clinical use.
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Affiliation(s)
- M G Revello
- Fondazione IRCCS Policlinico San Matteo, SC Ostetricia e Ginecologia, Pavia, Italy
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Dickstein Y, Ohel I, Levy A, Holcberg G, Sheiner E. Lack of prenatal care: an independent risk factor for perinatal mortality among macrosomic newborns. Arch Gynecol Obstet 2007; 277:511-4. [DOI: 10.1007/s00404-007-0510-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 10/30/2007] [Indexed: 11/24/2022]
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Dickstein Y, Schwartz H, Gross J, Gordon A. Stimulation of sugar transport in cultured heart cells by triiodothyronine (T3) covalently bound to red blood cells and by T3 in the presence of serum. Endocrinology 1983; 113:391-8. [PMID: 6683153 DOI: 10.1210/endo-113-1-391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
T3, covalently bound to red blood cells (RBCs), stimulated the uptake rate of 2-deoxy-D-glucose (2-DOG) in cultured chick embryo heart cells. The response, measured 6 h after exposure, was at least the same than that to free T3. An inhibitor of rhodamine-T3 internalization, bacitracin, did not affect the stimulation of sugar uptake by T3 regardless of whether T3 was covalently bound or free. Pretreatment of RBC-T3 with anti-T3 immunoglobulin G completely blocked the effect of T3, whereas normal rabbit immunoglobulin G failed to do so. Addition of 5% chick serum to the medium stimulated 2-DOG uptake to 144% of the control at 6 h. Adding T3 (10 nM) to the serum-containing medium increased 2-DOG uptake to 171% of the control. The effect of T3 alone or in the presence of serum was not inhibited by cycloheximide, puromycin, or actinomycin D. A T3 dose response curve, in medium containing 10% dehormonized serum, showed enhancement of the T3 effect when compared with the curve obtained in the serum-free medium. The minimal effective concentration of T3 was 10 pM in the presence of serum and 100 pM in its absence. The slope of the linear portion of the dose response curve was greatly increased and the maximal response markedly enhanced by serum. The ED50 was 0.33 nM vs. 0.43 nM in terms of total T3 concentration and 0.16 nM vs. 0.43 nM in terms of free T3 in the presence or absence of serum, respectively. These data suggest that T3, in physiological concentrations, activates sugar transport through an external contact with the cell surface.
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Schwalb H, Dickstein Y, Heller M. Interactions of cardiac glycosides with cardiac cells. III. Alterations in the sensitivity of (Na+ +K+)-ATPase to inhibition by ouabain in rat hearts. Biochim Biophys Acta 1982; 689:241-8. [PMID: 6126212 DOI: 10.1016/0005-2736(82)90256-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Spitz IM, Zylber-Haran EA, Trestian S, Dickstein Y, Palti Z, Schenker JG. The decreased basal and stimulated prolactin levels in isolated gonadotrophin deficiency: a consequence of the low oestrogen state. Clin Endocrinol (Oxf) 1982; 16:423-32. [PMID: 6282502 DOI: 10.1111/j.1365-2265.1982.tb02756.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Thyroxine (T4) and tri-iodothyronine (T3) were metabolized in cultured chick-embryo heart cells via inner-ring de-iodination and O-sulfation. The products of T3 metabolism were 3,3'T2, 3'T1, and sulfated esters of T3 and 3,3'T2. The major product of T4 degradation was 3,3',5'-T3 (rT3). ONo T3 was produced from T4. Propylthioracil inhibited the metabolism of T3. Pretreatment of cultures with T3 or T4 enhanced the metabolism of both hormones; actinomycin D and cycloheximide inhibited the stimulatory effect of T3. The stimulation by T3 was linearly related to the log of the concentration of T3 in cells grown in normal chick serum or in cells grown in dehormonized serum. These results suggest that thyroid hormones induced an increased synthesis of the enzymes involved in their metabolism and therefore may regulate their own disposal rate.
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