Archive for December 30, 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


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