Archive for January, 2018

Ceftriaxone versus ceftriaxone plus a macrolide for community-acquired pneumonia in hospitalized patients with HIV/AIDS: a randomized controlled trial

Clinical Microbiology and Infection February 2018 V.24 N.2 p146–151 

Figueiredo-Mello, P. Naucler, M.D. Negra, A.S. Levin

Objectives

To evaluate if treatment with ceftriaxone and a macrolide, improved patient outcome when compared with monotherapy with ceftriaxone, in hospitalized patients with human immunodeficiency virus/acquired immunodeficient syndrome (HIV/AIDS) with community-acquired pneumonia (CAP).

Methods

Adult patients with HIV hospitalized due to suspected CAP were randomized to receive one of two regimens, ceftriaxone plus macrolide or ceftriaxone plus placebo, at a 1:1 proportion (Brazilian Clinical Trials Registry: RBR-8wtq2b). The primary outcome was in-hospital mortality and the secondary outcomes were mortality within 14 days, need for vasoactive drugs, need for mechanical ventilation, time to clinical stability and length of hospitalization.

Results

A total of 227 patients were randomized, two were excluded after randomization; 225 patients were analysed (112 receiving ceftriaxone plus placebo and 113 receiving ceftriaxone plus macrolide). The frequency of the primary outcome, in-hospital mortality, was not statistically different between the regimens: 12/112 (11%) patients who received ceftriaxone plus placebo and 17/113 (15%) who received ceftriaxone plus macrolide died during hospitalization (hazard ratio 1.22, 95% CI 0.57–2.59). We did not find differences between the regimens for any of the secondary outcomes, including mortality within 14 days, which occurred in 5/112 (4%) patients with ceftriaxone plus placebo and in 12/113 (11%) patients with ceftriaxone plus macrolide (relative risk 2.38, 95% CI 0.87–6.53).

Conclusions

Among hospitalized patients with HIV/AIDS with CAP, treatment with ceftriaxone and a macrolide did not improve patient outcomes, when compared with ceftriaxone monotherapy.

abstract

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30332-4/fulltext

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30332-4/pdf

 

January 31, 2018 at 11:25 pm

Is a randomized trial of a short course of aminoglycoside added to β-lactam antibiotics for empirical treatment in critically ill patients with sepsis justified?

Clinical Microbiology and Infection February 2018 V.24 N.2 p.95–96    

D.S.Y. Ong, C.H. van Werkhoven, O.L. Cremer, G.E. Thwaites, M.J.M. Bonten

Aminoglycosides are among the most widely used antibiotics in intensive care units (ICU), despite demonstrated absence of survival benefits when added to β-lactam therapy and higher rates of adverse effects, such as nephrotoxicity, in patients with sepsis [1.

Yet most studies evaluated prolonged courses of aminoglycosides, used multiple daily dosing schedules or compared broad-spectrum β-lactam monotherapy to a combination of an aminoglycoside with a less broad-spectrum β-lactam.

As short courses (i.e. ❤ days) of once-daily dosing of aminoglycosides yield less nephrotoxicity, it has been suggested that such combination therapy might be beneficial in severely ill patients, such as those admitted to ICU with sepsis or septic shock [2.

Addition of an aminoglycoside broadens the antibacterial spectrum and thus reduces the risk of inadequate empirical treatment, and it may enhance bacterial killing in the bloodstream.

Short-term adjunctive treatment with aminoglycosides for the empirical treatment of sepsis in critically ill patients is recommended in some [[3], [4], [5]] …

abstract

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30535-9/fulltext

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30535-9/pdf

January 31, 2018 at 11:23 pm

Colistin antimicrobial susceptibility testing—can the slow and challenging be replaced by the rapid and convenient?

Clinical Microbiology and Infection February 2018 V.24 N.2 p.93–94    

C.G. Giske, G. Kahlmeter

In a recent paper by Jayol et al., the authors compare three methods for antimicrobial susceptibility testing of colistin [1.

Clinical Enterobacteriaceae isolates (83 colistin-resistant and 40 colistin-susceptible) were tested with the broth microdilution methodology (BMD), the BD Phoenix automated system and the Rapid Polymyxin NP test.

The BMD was considered the reference. Molecular mechanisms responsible for plasmid-mediated and chromosomally encoded colistin-resistance mechanisms were determined by PCR and sequencing.

The BD Phoenix system failed to detect ten colistin-resistant isolates (one Escherichia coli, one Klebsiella pneumoniae, seven Enterobacter spp. and one Salmonella enterica).

The Rapid Polymyxin NP test failed to detect the same E. coli isolate, but otherwise performed well.

The BD Phoenix system exhibited poor performance in species other than E. coli and K. pneumoniae, where there was one failure in each species….

abstract

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30569-4/fulltext

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30569-4/pdf

January 31, 2018 at 11:22 pm

Healthcare personnel intestinal colonization with multidrug-resistant organisms

Clinical Microbiology and Infection January 2018 V.24 N.1 p82.e1–82.e4   

B.K. Decker, A.F. Lau, J.P. Dekker, C.D. Spalding, N. Sinaii, S. Conlan, D.K. Henderson, J.A. Segre, K.M. Frank, T.N. Palmore

Objectives

This study aims to assess the association between patient contact and intestinal carriage of multidrug-resistant organisms (MDRO) by sampling healthcare personnel (HCP) and staff without patient contact.

Methods

For this observational study, we recruited 400 HCP who worked in our 200-bed research hospital and 400 individuals without patient contact between November 2013 and February 2015. Participants submitted two self-collected perirectal swabs and a questionnaire. Swabs were processed for multidrug-resistant Gram-negative bacteria and vancomycin-resistant enterococci (VRE). Questionnaires explored occupational and personal risk factors for MDRO carriage.

Results

Among 800 participants, 94.4% (755/800) submitted at least one swab, and 91.4% (731/800) also submitted questionnaires. Extended spectrum β-lactamase-producing organisms were recovered from 3.4% (26/755) of participants, and only one carbapenemase-producing organism was recovered. No VRE were detected. The potential exposure of 68.9% (250/363) of HCP who reported caring for MDRO-colonized patients did not result in a rate of MDRO carriage among HCP (4.0%; 15/379) significantly higher than that of staff without patient contact (3.2%; 12/376; p 0.55).

Conclusions

This is the largest US study of HCP intestinal MDRO carriage. The low colonization rate is probably reflective of local community background rates, suggesting that HCP intestinal colonization plays a minor role in nosocomial spread of MDROs in a non-outbreak setting.

abstract

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30270-7/fulltext

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(17)30270-7/pdf

January 31, 2018 at 11:21 pm

An Analysis of the Epidemic of Klebsiella pneumoniae Carbapenemase-Producing K. pneumoniae: Convergence of Two Evolutionary Mechanisms Creates the “Perfect Storm”

The Journal of Infectious Diseases  December 27, 2017 V.217 N.1 P.82–92     

Laura J Rojas; George M Weinstock; Elsa De La Cadena; Lorena Diaz; Rafael Rios …

Background

Carbapenem resistance is a critical healthcare challenge worldwide. Particularly concerning is the widespread dissemination of Klebsiella pneumoniae carbapenemase (KPC). Klebsiella pneumoniae harboring blaKPC (KPC-Kpn) is endemic in many areas including the United States, where the epidemic was primarily mediated by the clonal dissemination of Kpn ST258. We postulated that the spread of blaKPC in other regions occurs by different and more complex mechanisms. To test this, we investigated the evolution and dynamics of spread of KPC-Kpn in Colombia, where KPC became rapidly endemic after emerging in 2005.

Methods

We sequenced the genomes of 133 clinical isolates recovered from 24 tertiary care hospitals located in 10 cities throughout Colombia, between 2002 (before the emergence of KPC-Kpn) and 2014. Phylogenetic reconstructions and evolutionary mapping were performed to determine temporal and genetic associations between the isolates.

Results

Our results indicate that the start of the epidemic was driven by horizontal dissemination of mobile genetic elements carrying blaKPC-2, followed by the introduction and subsequent spread of clonal group 258 (CG258) isolates containing blaKPC-3.

Conclusions

The combination of 2 evolutionary mechanisms of KPC-Kpn within a challenged health system of a developing country created the “perfect storm” for sustained endemicity of these multidrug-resistant organisms in Colombia.

abstract

https://academic.oup.com/jid/article/217/1/82/4259398

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January 31, 2018 at 11:20 pm

Impact of Rapid Susceptibility Testing and Antibiotic Selection Strategy on the Emergence and Spread of Antibiotic Resistance in Gonorrhea

The Journal of Infectious Diseases November 27, 2017 V.216 N.9  P.1141–1149  

Ashleigh R Tuite; Thomas L Gift; Harrell W Chesson; Katherine Hsu; Joshua A Salomon …

Background

Increasing antibiotic resistance limits treatment options for gonorrhea. We examined the impact of a hypothetical point-of-care (POC) test reporting antibiotic susceptibility profiles on slowing resistance spread.

Methods

A mathematical model describing gonorrhea transmission incorporated resistance emergence probabilities and fitness costs associated with resistance based on characteristics of ciprofloxacin (A), azithromycin (B), and ceftriaxone (C). We evaluated time to 1% and 5% prevalence of resistant strains among all isolates with the following: (1) empiric treatment (B and C), and treatment guided by POC tests determining susceptibility to (2) A only and (3) all 3 antibiotics.

Results

Continued empiric treatment without POC testing was projected to result in >5% of isolates being resistant to both B and C within 15 years. Use of either POC test in 10% of identified cases delayed this by 5 years. The 3 antibiotic POC test delayed the time to reach 1% prevalence of triply-resistant strains by 6 years, whereas the A-only test resulted in no delay. Results were less sensitive to assumptions about fitness costs and test characteristics with increasing test uptake.

Conclusions

Rapid diagnostics reporting antibiotic susceptibility may extend the usefulness of existing antibiotics for gonorrhea treatment, but ongoing monitoring of resistance patterns will be critical.

abstract

https://academic.oup.com/jid/article/216/9/1141/4100269

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January 31, 2018 at 11:18 pm

Rhinovirus Viremia in Patients Hospitalized With Community-Acquired Pneumonia

The Journal of Infectious Diseases  November 27, 2017 V.216 N.9 P.1104–1111    

Xiaoyan Lu; Eileen Schneider; Seema Jain; Anna M Bramley; Weston Hymas

Background

Rhinoviruses (RVs) are ubiquitous respiratory pathogens that often cause mild or subclinical infections. Molecular detection of RVs from the upper respiratory tract can be prolonged, complicating etiologic association in persons with severe lower respiratory tract infections. Little is known about RV viremia and its value as a diagnostic indicator in persons hospitalized with community-acquired pneumonia (CAP).

Methods

Sera from RV-positive children and adults hospitalized with CAP were tested for RV by real-time reverse-transcription polymerase chain reaction. Rhinovirus species and type were determined by partial genome sequencing.

Results

Overall, 57 of 570 (10%) RV-positive patients were viremic, and all were children aged <10 years (n = 57/375; 15.2%). Although RV-A was the most common RV species detected from respiratory specimens (48.8%), almost all viremias were RV-C (98.2%). Viremic patients had fewer codetected pathogens and were more likely to have chest retractions, wheezing, and a history of underlying asthma/reactive airway disease than patients without viremia.

Conclusions

More than 1 out of 7 RV-infected children aged <10 years hospitalized with CAP were viremic. In contrast with other RV species, RV-C infections were highly associated with viremia and were usually the only respiratory pathogen identified, suggesting that RV-C viremia may be an important diagnostic indicator in pediatric pneumonia.

abstract

https://academic.oup.com/jid/article/216/9/1104/4096795

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January 31, 2018 at 11:16 pm

Long-term acute care hospitals.

Clinical Infectious Diseases August 1, 2009  V.49 N.3 P.438-43.     

Munoz-Price LS1.

Author information

1 simunozprice@gmail.com

Abstract

Long-term acute care hospitals (LTACHs) are health care facilities that admit complex patients with acute care needs (eg, mechanical ventilator weaning, administration of intravenous antibiotics, and complex wound care) for a mean duration of stay of 25 days. LTACHs are different than nursing homes and were initially created in the 1990s in an effort to decrease Medicare costs by facilitating prompt discharge from intensive care units of patients with difficulty weaning mechanical ventilation; however, current admission diagnoses are quite broad. Patients admitted to these facilities have multiple comorbidities and are at risk for colonization with multidrug-resistant organisms. LTACH patients have been shown to have high rates of hospital-acquired infections, including central vascular catheter-associated bloodstream infection and ventilator-associated pneumonia. In addition, LTACHs have been implicated in various regional outbreaks of multidrug-resistant organisms. This review summarizes the limited amount of scientific literature on LTACHs while highlighting their infection control problems, as well as the role LTACHs play on regional outbreaks.

abstract

https://academic.oup.com/cid/article/49/3/438/499066

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January 30, 2018 at 4:08 pm

Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices

BMJ Journals 2014

Martin C Gulliford1, Alex Dregan1, Michael V Moore2, Mark Ashworth1, Tjeerd van Staa3,4, Gerard McCann3, Judith Charlton1, Lucy Yardley2, Paul Little2, Lisa McDermott1

Author affiliations

King’s College London, Primary Care and Public Health Sciences, London, UK

Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK

Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, UK

Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, London, UK

Abstract

Objectives

Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults.

Setting

Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink.

Participants

Participants were adults aged 18–59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat.

Primary and secondary outcome measures

For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated.

Results

There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for ‘colds and upper RTIs’, 48% for ‘cough and bronchitis’, 60% for ‘sore throat’, 60% for ‘otitis-media’ and 91% for ‘rhino-sinusitis’. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for ‘colds’, 67% for ‘cough’, 78% for ‘sore throat’, 90% for ‘otitis-media’ and 100% for ‘rhino-sinusitis’.

Conclusions

Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.

FULL TEXT

http://bmjopen.bmj.com/content/4/10/e006245.long

PDF

http://bmjopen.bmj.com/content/bmjopen/4/10/e006245.full.pdf

 

January 30, 2018 at 3:41 pm

Genomic epidemiology and antimicrobial resistance of Neisseria gonorrhoeae in New Zealand

Journal of Antimicrobial Chemotherapy February 2018 V.73 N.2 P.353–364  

Robyn S Lee; Torsten Seemann; Helen Heffernan; Jason C Kwong; Anders Gonçalves da Silva …

Background

Antimicrobial-resistant Neisseria gonorrhoeae is a major threat to public health. No studies to date have examined the genomic epidemiology of gonorrhoea in the Western Pacific Region, where the incidence of gonorrhoea is particularly high.

Methods

A population-level study of N. gonorrhoeae in New Zealand (October 2014 to May 2015). Comprehensive susceptibility testing and WGS data were obtained for 398 isolates. Relatedness was inferred using phylogenetic trees, and pairwise core SNPs. Mutations and genes known to be associated with resistance were identified, and correlated with phenotype.

Results

Eleven clusters were identified. In six of these clusters, >25% of isolates were from females, while in eight of them, >15% of isolates were from females. Drug resistance was common; 98%, 32% and 68% of isolates were non-susceptible to penicillin, ciprofloxacin and tetracycline, respectively. Elevated MICs to extended-spectrum cephalosporins (ESCs) were observed in 3.5% of isolates (cefixime MICs ≥ 0.12 mg/L, ceftriaxone MICs ≥ 0.06 mg/L). Only nine isolates had penA XXXIV genotypes, three of which had decreased susceptibility to ESCs (MIC = 0.12 mg/L). Azithromycin non-susceptibility was identified in 43 isolates (10.8%); two of these isolates had 23S mutations (C2611T, 4/4 alleles), while all had mutations in mtrR or its promoter.

Conclusions

The high proportion of females in clusters suggests transmission is not exclusively among MSM in New Zealand; re-assessment of risk factors for transmission may be warranted in this context. As elevated MICs of ESCs and/or azithromycin were found in closely related strains, targeted public health interventions to halt transmission are urgently needed.

abstract

https://academic.oup.com/jac/article/73/2/353/4647718

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January 28, 2018 at 7:40 pm

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