Archive for December, 2016

Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastrointestinal endoscopy.

World J Gastrointest Endosc. 2014 Oct 16;6(10):457-74.

Muscarella LF1.

Author information

1Lawrence F Muscarella, LFM Healthcare Solutions, LLC, Montgomeryville, PA 18936, United States.

Abstract

To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae (CRE) and their related superbugs during gastrointestinal (GI) endoscopy. Reports of outbreaks linked to GI endoscopes contaminated with different types of infectious agents, including CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE’s emergence, these reports were obtained by searching the peer-reviewed medical literature (via the United States National Library of Medicine’s “MEDLINE” database); the Food and Drug Administration’s Manufacturer and User Facility Device Experience database, or “MAUDE”; and the Internet (via Google’s search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at “Hospital X” located in the suburbs of Chicago (IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital’s patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Control and Prevention (CDC), which published a report about this outbreak in Morbidity and Mortality Weekly Report (MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X’s infection control practices following this CRE outbreak, were also reviewed. While this article focuses primarily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infectious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently associated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospital X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer’s labeling, supplemented as needed with professional organizations’ published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including bronchoscopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endoscopy. Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind and near the forceps elevator located at the distal end of the ERCP endoscope, are recommended. If the ERCP endoscope features a narrow and exposed channel that houses a wire connecting the GI endoscope’s control head to this forceps elevator, then this channel’s complete reprocessing, including its flushing with a detergent using a procedure validated for effectiveness, is also emphasized.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4198391/pdf/WJGE-6-457.pdf

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December 30, 2016 at 7:54 am

Efficacy of polymyxins in the treatment of carbapenem-resistant Enterobacteriaceae infections: a systematic review and meta-analysis.

Braz J Infect Dis. 2015 Mar-Apr;19(2):170-80.

Ni W1, Cai X1, Wei C1, Di X2, Cui J3, Wang R2, Liu Y1.

Author information

1Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China.

2Department of Clinical Pharmacology, Chinese People’s Liberation Army General Hospital, Beijing, China.

3Department of Respiratory Diseases, Chinese People’s Liberation Army General Hospital, Beijing, China. Electronic address: guoguoyoumeng@163.com.

Abstract

In recent years, carbapenem-resistant Enterobacteriaceae has become endemic in many countries. Because of limited treatment options, the abandoned “old antibiotics”, polymyxins, have been reintroduced to the clinic.

To evaluate the clinical efficacy of polymyxins in the treatment of infections caused by carbapenem-resistant Enterobacteriaceae, we systemically searched the PubMed, Embase, and Cochrane Library databases and analyzed the available evidence.

The Preferred Reporting Items for Systematic reviews and Meta-Analysis statement were followed, and the I(2) method was used for heterogeneity. Nineteen controlled and six single-arm cohort studies comprising 1086 patients met the inclusion criteria.

For controlled studies, no significant difference was noted for overall mortality (OR, 0.79; 95% CI, 0.58-1.08; p=0.15), clinical response rate (OR, 1.24; 95% CI, 0.61-2.54; p=0.55), or microbiological response rate (OR, 0.59; 95% CI, 0.26-1.36; p=0.22) between polymyxin-treated groups and the control groups.

Subgroup analyses showed that 28-day or 30-day mortality was lower in patients who received polymyxin combination therapy than in those who received monotherapy (OR, 0.36; 95% CI, 0.19-0.68; p<0.01) and the control groups (OR, 0.49; 95% CI, 0.31-0.75; p<0.01).

The results of the six single-arm studies were in accordance with the findings of controlled studies. One controlled and two single-arm studies that evaluated the occurrence of nephrotoxicity reported a pooled incidence rate of 19.2%.

Our results suggest that polymyxins may be as efficacious as other antimicrobial therapies for the treatment of carbapenem-resistant Enterobacteriaceae infection. Compared to polymyxin monotherapy, combination regimens may achieve lower 28-day or 30-day mortality.

Future large-volume, well-designed randomized control trials are required to determine the role of polymyxins in treating carbapenem-resistant Enterobacteriaceae infections.

PDF

http://ac.els-cdn.com/S1413867015000252/1-s2.0-S1413867015000252-main.pdf?_tid=78c2f2f6-451c-11e6-9f31-00000aab0f6c&acdnat=1467990106_cdb16b4e613e485d667dfb318f5a5d85

December 30, 2016 at 7:52 am

Carbapenemase-producing Enterobacteriaceae.

Semin Respir Crit Care Med. 2015 Feb;36(1):74-84.

Doi Y1, Paterson DL2.

Author information

1Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

2The University of Queensland Centre for Clinical Research, Royal Brisbane and Women’s Hospital, Brisbane, Australia.

Abstract

Carbapenemase-producing Enterobacteriaceae (CPE) were almost nonexistent up to the 1990s, but are today encountered routinely in hospitals and other healthcare facilities in many countries including the United States.

KPC-producing Klebsiella pneumoniae was the first to emerge and spread globally and is endemic in the United States, Israel, Greece, and Italy.

Recently, NDM-producing Enterobacteriaceae and OXA-48-producing K. pneumoniae appear to be disseminating from South Asia and Northern Africa, respectively.

They are almost always resistant to all β-lactams including carbapenems and many other classes. Mortality from invasive CPE infections reaches up to 40%.

To obtain the maximal benefit from the limited options available, dosing of antimicrobial agents should be optimized based on pharmacokinetic data, especially for colistin and carbapenems.

In addition, multiple observational studies have associated combination antimicrobial therapy with lower mortality compared with monotherapy for these infections.

The outcomes appear to be especially favorable when patients are treated with a carbapenem and a second agent such as colistin, tigecycline, and gentamicin, but the best approach is yet to be defined.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4470611/pdf/nihms698044.pdf

December 30, 2016 at 7:50 am

Treatment Options for Carbapenem-Resistant Enterobacteriaceae Infections.

Open Forum Infect Dis. 2015 May 5;2(2):ofv050.

Morrill HJ1, Pogue JM2, Kaye KS3, LaPlante KL4.

Author information

1Veterans Affairs Medical Center , Infectious Diseases Research Program , Providence, Rhode Island ; College of Pharmacy, Department of Pharmacy Practice , University of Rhode Island , Kingston.

2Department of Pharmacy Services.

3Division of Infectious Diseases , Detroit Medical Center, Wayne State University , Michigan.

4Veterans Affairs Medical Center , Infectious Diseases Research Program , Providence, Rhode Island ; College of Pharmacy, Department of Pharmacy Practice , University of Rhode Island , Kingston ; Division of Infectious Diseases , Warren Alpert Medical School of Brown University , Providence, Rhode Island.

Abstract

This article provides a comprehensive review of currently available treatment options for infections due to carbapenem-resistant Enterobacteriaceae (CRE).

Antimicrobial resistance in Gram-negative bacteria is an emerging and serious global public health threat. Carbapenems have been used as the “last-line” treatment for infections caused by resistant Enterobacteriaceae, including those producing extended spectrum ß-lactamases.

However, Enterobacteriaceae that produce carbapenemases, which are enzymes that deactivate carbapenems and most other ß-lactam antibiotics, have emerged and are increasingly being reported worldwide.

Despite this increasing burden, the most optimal treatment for CRE infections is largely unknown. For the few remaining available treatment options, there are limited efficacy data to support their role in therapy.

Nevertheless, current treatment options include the use of older agents, such as polymyxins, fosfomycin, and aminoglycosides, which have been rarely used due to efficacy and/or toxicity concerns.

Optimization of dosing regimens and combination therapy are additional treatment strategies being explored. Carbapenem-resistant Enterobacteriaceae infections are associated with poor outcomes and high mortality.

Continued research is critically needed to determine the most appropriate treatment.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462593/pdf/ofv050.pdf

December 30, 2016 at 7:48 am

Report of mecC-carrying MRSA in domestic swine

Journal of Antimicrobial & Chemotherapy January 1, 2017 V.72 N.1 P.60-63

Ø. Angen, M. Stegger, J. Larsen, B. Lilje, H. Kaya, K. S. Pedersen, A. Jakobsen, A. Petersen, and A. R. Larsen

1Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S, Denmark

2Ø-Vet, Køberupvej 33, 4700 Næstved, Denmark

Objectives

We unexpectedly identified MRSA isolates carrying mecC (mecC-MRSA) from a Danish swine farm located in eastern Zealand. The objective of the present study was to investigate the origin of these isolates and their genetic relatedness to other mecC-MRSA isolates from Zealand.

Methods

WGS was used to infer the phylogenetic relationship between 19 identified mecC-MRSA isolates from the swine farm and 34 additional epidemiologically unrelated human isolates from the same geographical region of Denmark. Variations in the accessory genome were investigated by bioinformatics tools, and antibiotic susceptibility profiles were assessed by MIC determination.

Results

mecC-MRSA was isolated from a domestic swine farm, but not from cattle reared at the same farm. Phylogenetic analysis revealed that all mecC-MRSA isolates from both farm animals and workers formed a separate cluster, whereas human isolates from the same municipality belonged to a closely related cluster. Analysis of the accessory genome supported this relationship.

Conclusions

To the best of our knowledge, this is the first report of mecC-MRSA isolated from domestic swine. The investigation strongly indicates that transmission of mecC-MRSA has taken place on the swine farm between the farmers and swine. The close clustering of farm isolates and isolates from the same municipality suggests a local transmission of mecC-MRSA.

PDF

http://jac.oxfordjournals.org/content/72/1/60.full.pdf+html

December 28, 2016 at 8:09 am

Review – Role of cephalosporins in the era of Clostridium difficile infection

Journal of Antimicrobial & Chemotherapy January 1, 2017 V.72 N.1 P.1-18

Mark H. Wilcox, James D. Chalmers, Carl E. Nord, Jane Freeman, and Emilio Bouza

1Leeds Institute of Biomedical and Clinical Sciences, Faculty of Medicine and Health, University of Leeds, and Microbiology, Leeds Teaching Hospitals, Leeds, UK

2Tayside Respiratory Research Group, University of Dundee, Dundee, UK

3Department of Laboratory Medicine, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden

4Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain

The incidence of Clostridium difficile infection (CDI) in Europe has increased markedly since 2000.

Previous meta-analyses have suggested a strong association between cephalosporin use and CDI, and many national programmes on CDI control have focused on reducing cephalosporin usage.

Despite reductions in cephalosporin use, however, rates of CDI have continued to rise.

This review examines the potential association of CDI with cephalosporins, and considers other factors that influence CDI risk.

EUCLID (the EUropean, multicentre, prospective biannual point prevalence study of CLostridium difficile Infection in hospitalized patients with Diarrhoea) reported an increase in the annual incidence of CDI from 6.6 to 7.3 cases per 10 000 patient bed-days from 2011–12 to 2012–13, respectively.

While CDI incidence and cephalosporin usage varied widely across countries studied, there was no clear association between overall cephalosporin prescribing (or the use of any particular cephalosporin) and CDI incidence.

Moreover, variations in the pharmacokinetic and pharmacodynamic properties of cephalosporins of the same generation make categorization by generation insufficient for predicting impact on gut microbiota.

A multitude of additional factors can affect the risk of CDI. Antibiotic choice is an important consideration; however, CDI risk is associated with a range of antibiotic classes.

Prescription of multiple antibiotics and a long duration of treatment are key risk factors for CDI, and risk also differs across patient populations.

We propose that all of these are factors that should be taken into account when selecting an antibiotic, rather than focusing on the exclusion of individual drug classes.

PDF

http://jac.oxfordjournals.org/content/72/1/1.full.pdf+html

December 28, 2016 at 8:07 am

Halicephalobus gingivalis – a rare cause of fatal meningoencephalomyelitis in humans.

Am J Trop Med Hyg. 2013 Jun;88(6):1062-4.

Papadi B1, Boudreaux C, Tucker JA, Mathison B, Bishop H, Eberhard ME.

Author information

1University of South Alabama Medical Center, Mobile, AL, USA. bhavesh2papadi@yahoo.com

Abstract

The genus Halicephalobus consists of eight species of free-living nematodes. Only one species (H. gingivalis) has been reported to infect vertebrates.

Human infection is extremely rare, and only four cases have been reported in the literature.

These nematodes seem to exhibit neurotropism, but their life cycle, mode of infection, and risk factors are poorly understood.

Neurohelminthiases are not commonly recognized in the United States and when they do occur, pose great diagnostic challenges because of lack of appropriate non-invasive screening and/or confirmatory tests.

We report a challenging case of meningoencephalomyelitis caused by a Halicephalobus sp., in which the patient had a rapidly deteriorating clinical course.

The case did not raise any clinical suspicion of neurohelminthiases, although increased eosinophils were present in the cerebrospinal fluid.

This case presents an opportunity to highlight the importance of considering parasitic infection in meningoencephalitis or meningoencephalomyelitis presenting atypically.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752803/pdf/tropmed-88-1062.pdf

December 26, 2016 at 1:27 pm

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