Posts filed under ‘Resistencia bacteriana’
Bloodstream infections in intensive care unit patients: distribution and antibiotic resistance of bacteria.
Infect Drug Resist. 2015 Aug 10;8:287-96.
Russotto V1, Cortegiani A1, Graziano G2, Saporito L2, Raineri SM1, Mammina C2, Giarratano A1.
1Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Paolo Giaccone University Hospital, University of Palermo, Palermo, Italy.
2Department of Sciences for Health Promotion and Mother-Child Care, University of Palermo, Palermo, Italy.
Bloodstream infections (BSIs) are among the leading infections in critically ill patients. The case-fatality rate associated with BSIs in patients admitted to intensive care units (ICUs) reaches 35%-50%.
The emergence and diffusion of bacteria with resistance to antibiotics is a global health problem. Multidrug-resistant bacteria were detected in 50.7% of patients with BSIs in a recently published international observational study, with methicillin resistance detected in 48% of Staphylococcus aureus strains, carbapenem resistance detected in 69% of Acinetobacter spp., in 38% of Klebsiella pneumoniae, and in 37% of Pseudomonas spp.
Prior hospitalization and antibiotic exposure have been identified as risk factors for infections caused by resistant bacteria in different studies.
Patients with BSIs caused by resistant strains showed an increased risk of mortality, which may be explained by a higher incidence of inappropriate empirical therapy in different studies.
The molecular genetic characterization of resistant bacteria allows the understanding of the most common mechanisms underlying their resistance and the adoption of surveillance measures.
Knowledge of epidemiology, risk factors, mechanisms of resistance, and outcomes of BSIs caused by resistant bacteria may have a major influence on global management of ICU patients.
The aim of this review is to provide the clinician an update on BSIs caused by resistant bacteria in ICU patients.
Dalbavancin: A Novel Lipoglycopeptide Antibiotic with Extended Activity Against Gram-Positive Infections.
Infect Dis Ther. 2015 Sep;4(3):245-58.
Smith JR1, Roberts KD2, Rybak MJ3.
1High Point University School of Pharmacy, 833 Montlieu Avenue, High Point, NC, 27265, USA.
2St. Vincent Indianapolis, 2001 W. 86th Street, Indianapolis, IN, 46260, USA.
3Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, 259 Mack Avenue, Detroit, MI, 48201, USA. firstname.lastname@example.org
Dalbavancin is a lipoglycopeptide antibiotic recently approved by the United States Food and Drug Administration (FDA) for acute bacterial skin and skin structure infections (ABSSSIs). It is active against gram-positive pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), and minimum inhibitory concentrations (MICs) are consistently <0.125 µg/ml, much lower than most other anti-MRSA agents. Dalbavancin possesses an extended half-life of over 1 week, allowing an initial dose of 1000 mg followed by 500 mg 1 week later to complete a course of therapy for ABSSSI. It is approximately 95% protein bound and is widely distributed throughout the body, achieving concentrations similar to plasma levels in numerous tissues. Against MRSA, dalbavancin is 4-8 times more potent than vancomycin in vitro, and limited data suggest it possesses activity against MRSA with reduced susceptibility to vancomycin such as hVISA and VISA. Dalbavancin also possesses in vitro activity against streptococci and enterococci, although activity against vancomycin-resistant enterococci is lacking. In phase 3 ABSSSI studies, dalbavancin demonstrated similar activity to vancomycin and provides a more convenient dosing regimen. Limited phase 2 data suggest dalbavancin also possesses activity in catheter-related bloodstream infections. Potential further therapeutic uses include conditions that require long-term treatment such as osteomyelitis and infective endocarditis, although data are currently lacking. The extended half-life of dalbavancin, along with its in vitro activity against gram-positive organisms with reduced susceptibility to other anti-MRSA antibiotics, suggest it could have an exciting clinical role going forward.
Predictive factors for metastatic infection in patients with bacteremia caused by methicillin-sensitive Staphylococcus aureus.
Am J Med Sci. 2015 Jan;349(1):24-8.
Horino T1, Sato F, Hosaka Y, Hoshina T, Tamura K, Nakaharai K, Kato T, Nakazawa Y, Yoshida M, Hori S.
1Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Tokyo, Japan.
Metastatic infections such as infective endocarditis and psoas abscess are serious complications of Staphylococcus aureus bacteremia because failure to identify these infections may result in bacteremia relapse or poor prognosis. In the present study, we determined the predictive factors for metastatic infection due to methicillin-sensitive S. aureus bacteremia.
A retrospective cohort study was conducted among patients with methicillin-sensitive S. aureus bacteremia at the Jikei University Hospital between January 2008 and December 2012. Factors analyzed included the underlying disease, initial antimicrobial treatment and primary site of infection.
During the 5-year study period, 73 patients met the inclusion criteria and were assessed. The most common primary site of bacteremia was catheter-related bloodstream infection (25/73 [34.2%]). Metastatic infection occurred in 14 of 73 patients (19.2%) (infective endocarditis , septic pulmonary abscess , spondylitis , psoas abscess , epidural abscess  and septic arthritis ). Six patients had multiple metastatic infections. Multivariate analysis revealed that the predictive factors associated with the development of metastatic infection were a delay in appropriate antimicrobial treatment of >48 hours, persistent fever for >72 hours after starting antibiotic treatment and lowest C-reactive protein levels of >3 mg/dL during 2 weeks after the onset of bacteremia.
This study demonstrated that additional diagnostic tests should be conducted to identify metastatic infection, particularly in patients with delayed antimicrobial treatment, persistent fever and persistently high C-reactive protein levels.
Improving hospital hygiene to reduce the impact of multidrug-resistant organisms in health care-a prospective controlled multicenter study.
BMC Infect Dis. 2015 Oct 22;15:441.
Gerlich MG1, Piegsa J2, Schäfer C3, Hübner NO4, Wilke F5, Reuter S6, Engel G7, Ewert R8, Claus F9, Hübner C10, Ried W11, Flessa S12, Kramer A13, Hoffmann W14.
1Institut für Community Medicine, Ernst-Moritz-Arndt-Universität, Ellernholzstraße 1-2, 17487, Greifswald, Germany. email@example.com
2Institut für Community Medicine, Ernst-Moritz-Arndt-Universität, Ellernholzstraße 1-2, 17487, Greifswald, Germany. firstname.lastname@example.org
3Institut für Community Medicine, Ernst-Moritz-Arndt-Universität, Ellernholzstraße 1-2, 17487, Greifswald, Germany. email@example.com
4Institut für Hygiene und Umweltmedizin, Ernst-Moritz-Arndt-Universität, Walter-Rathenau-Straße 49a, 17475, Greifswald, Germany. firstname.lastname@example.org
5Institut für Hygiene und Umweltmedizin, Ernst-Moritz-Arndt-Universität, Walter-Rathenau-Straße 49a, 17475, Greifswald, Germany. email@example.com
6Universitätsapotheke, Ernst-Moritz-Arndt-Universität, Friedrich-Ludwig-Jahn-Straße 20, 17475, Greifswald, Germany. firstname.lastname@example.org
7Universitätsapotheke, Ernst-Moritz-Arndt-Universität, Friedrich-Ludwig-Jahn-Straße 20, 17475, Greifswald, Germany. email@example.com
8Zentrum für Innere Medizin, Klinik und Poliklinik für Innere Medizin B, Ernst-Moritz-Arndt-Universität, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany. firstname.lastname@example.org
9Lehrstuhl für Allgemeine Volkswirtschaftslehre und Finanzwissenschaft, Ernst-Moritz-Arndt-Universität, Friedrich-Loeffler-Straße 70, 17487, Greifswald, Germany. email@example.com
10Lehrstuhl für Allgemeine Betriebswirtschaftslehre und Gesundheitsmanagement, Ernst-Moritz-Arndt-Universität, Friedrich-Loeffler-Straße 70, 17487, Greifswald, Germany. firstname.lastname@example.org
11Lehrstuhl für Allgemeine Volkswirtschaftslehre und Finanzwissenschaft, Ernst-Moritz-Arndt-Universität, Friedrich-Loeffler-Straße 70, 17487, Greifswald, Germany. email@example.com
12Lehrstuhl für Allgemeine Betriebswirtschaftslehre und Gesundheitsmanagement, Ernst-Moritz-Arndt-Universität, Friedrich-Loeffler-Straße 70, 17487, Greifswald, Germany. firstname.lastname@example.org
13Institut für Hygiene und Umweltmedizin, Ernst-Moritz-Arndt-Universität, Walter-Rathenau-Straße 49a, 17475, Greifswald, Germany. email@example.com
14Institut für Community Medicine, Ernst-Moritz-Arndt-Universität, Ellernholzstraße 1-2, 17487, Greifswald, Germany. firstname.lastname@example.org
Nosocomial infections are the most common complication during inpatient hospital care. An increasing proportion of these infections are caused by multidrug-resistant organisms (MDROs). This report describes an intervention study which was designed to address the practical problems encountered in trying to avoid and treat infections caused by MDROs. The aim of the HARMONIC (Harmonized Approach to avert Multidrug-resistant Organisms and Nosocomial Infections) study is to provide comprehensive support to hospitals in a defined study area in north-east Germany, to meet statutory requirements. To this end, a multimodal system of hygiene management was implemented in the participating hospitals.
HARMONIC is a controlled intervention study conducted in eight acute care hospitals in the ‘Health Region Baltic Sea Coast’ in Germany. The intervention measures include the provision of written recommendations on methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and multi-resistant Gram-negative bacteria (MRGN), supplemented by regional recommendations for antibiotic prescriptions. In addition, there is theoretical and practical training of health care workers (HCWs) in the prevention and handling of MDROs, as well as targeted and critically gauged applications of antibiotics. The main outcomes of the implementation and analysis of the HARMONIC study are: (i) screening rates for MRSA, VRE and MRGN in high-risk patients, (ii) the frequency of MRSA decolonization, (iii) the level of knowledge of HCWs concerning MDROs, and (iv) specific types and amounts of antibiotics used. The data are predominantly obtained by paper-based questionnaires and documentation sheets. A computer-assisted workflow-based documentation system was developed in order to provide support to the participating facilities. The investigation includes three nested studies on risk profiles of MDROs, health-related quality of life, and cost analysis. A six-month follow-up study investigates the quality of life after discharge, the long-term costs of the treatment of infections caused by MDROs, and the sustainability of MRSA eradication.
The aim of this study is to implement and evaluate an area-wide harmonized hygiene program to control the nosocomial spreading of MDROs. Comparability between the intervention and control group is ensured by matching the hospitals according to size (number of discharges per year / number of beds) and level of care (standard or maximum). The results of the study may provide important indications for the implementation of regional MDRO management programs.
Colonization with resistant microorganisms in patients transferred from abroad: who needs to be screened?
Antimicrob Resist Infect Control. 2015 Jul 25;4:31.
Kaspar T1, Schweiger A2, Droz S3, Marschall J1.
1Department of Infectious Diseases and Prevention, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
2Department of Internal Medicine, University Hospital Basel, Basel, Switzerland.
3Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
While multi-drug resistant organisms (MDRO) are a global phenomenon, there are significant regional differences in terms of prevalence. Traveling to countries with a high MDRO prevalence increases the risk of acquiring such an organism. In this study we determined risk factors for MDRO colonization among patients who returned from a healthcare system in a high-prevalence area (so-called transfer patients). Factors predicting colonization could serve as screening criteria to better target those at highest risk.
This screening study included adult patients who had been exposed to a healthcare system abroad or in a high-prevalence region in Switzerland over the past six months and presented to our 950-bed tertiary care hospital between January 1, 2012 and December 31, 2013, a 24-month period. Laboratory screening tests focused on Gram-negative MDROs and methicillin-resistant Staphylococcus aureus (MRSA).
A total of 235 transfer patients were screened and analyzed, of which 43 (18 %) were positive for an MDRO. Most of them yielded Gram-negative bacteria (42; 98 %), with only a single screening revealing MRSA (2 %); three screenings showed a combination of Gram-negative bacteria and MRSA. For the risk factor analysis we focused on the 42 Gram-negative MDROs. Most of them were ESBL-producing Escherichia coli and Klebsiella pneumoniae while only two were carbapenemase producers. In univariate analysis, factors associated with screening positivity were hospitalization outside of Europe (p<0.001), surgical procedure in a hospital abroad (p=0.007), and – on admission to our hospital – active infection (p=0.002), antibiotic treatment (p=0.014) and presence of skin lesions (p=0.001). Only hospitalization outside of Europe (Odds Ratio, OR 3.2 (95 % CI 1.5- 6.8)) and active infection on admission (OR 2.7 (95 % CI 1.07- 6.6)) remained as independent predictors of Gram-negative MDRO colonization.
Our data suggest that a large proportion of patients (i.e., 82 %) transferred to Switzerland from hospitals in high MDRO prevalence areas are unnecessarily screened for MDRO colonization. Basing our screening strategy on certain criteria (such as presence of skin lesions, active infection, antibiotic treatment, history of a surgical procedure abroad and hospitalization outside of Europe) promises to be a better targeted and more cost-effective strategy.
Usefulness of previous methicillin-resistant Staphylococcus aureus screening results in guiding empirical therapy for S aureus bacteremia.
Can J Infect Dis Med Microbiol. 2015 Jul-Aug;26(4):201-6.
Bai AD1, Burry L2, Showler A3, Steinberg M4, Ricciuto D5, Fernandes T6, Chiu A6, Raybardhan S7, Tomlinson GA8, Bell CM9, Morris AM10.
1Faculty of Medicine, University of Ottawa, Ottawa;
2Mount Sinai Hospital, University of Toronto, Toronto; ; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto;
3Department of Medicine, University of Toronto, Toronto; ; Division of Infectious Diseases, University of Toronto, Toronto;
4Mount Sinai Hospital, University of Toronto, Toronto;
5Department of Medicine, University of Toronto, Toronto; ; Division of Infectious Diseases, University of Toronto, Toronto; ; Lakeridge Health, Oshawa, Queen’s University, Kingston; ; Department of Medicine, Queen’s University, Kingston;
6Trillium Health Partners, Mississauga;
7North York General Hospital, Toronto, Ontario.
8Department of Medicine, University of Toronto, Toronto; ; University Health Network, Toronto, Ontario.
9Mount Sinai Hospital, University of Toronto, Toronto; ; Department of Medicine, University of Toronto, Toronto; ; University Health Network, Toronto, Ontario ; Institute for Clinical Evaluative Sciences, Toronto, Ontario.
10Mount Sinai Hospital, University of Toronto, Toronto; ; Department of Medicine, University of Toronto, Toronto; ; Division of Infectious Diseases, University of Toronto, Toronto; ; University Health Network, Toronto, Ontario.
Abstractin English, French
Staphylococcus aureus bacteremia (SAB) is an important infection. Methicillin-resistant S aureus (MRSA) screening is performed on hospitalized patients for infection control purposes.
To assess the usefulness of past MRSA screening for guiding empirical antibiotic therapy for SAB.
A retrospective cohort study examined consecutive patients with confirmed SAB and previous MRSA screening swab from six academic and community hospitals between 2007 and 2010. Diagnostic test properties were calculated for MRSA screening swab for predicting methicillin resistance of SAB.
A total of 799 patients underwent MRSA screening swabs before SAB. Of the 799 patients, 95 (12%) had a positive and 704 (88%) had a negative previous MRSA screening swab. There were 150 (19%) patients with MRSA bacteremia. Overall, previous MRSA screening swabs had a positive likelihood ratio of 33 (95% CI 18 to 60) and a negative likelihood ratio of 0.45 (95% CI 0.37 to 0.54). Diagnostic accuracy differed depending on mode of acquisition (ie, community-acquired, nosocomial or health care-associated infection) (P<0.0001) and hospital (P=0.0002). At best, for health care-associated infection, prior MRSA screening swab had a positive likelihood ratio of 16 (95% CI 9 to 28) and a negative likelihood ratio of 0.27 (95% CI 0.17 to 0.41).
A negative prior MRSA screening swab cannot reliably rule out MRSA bacteremia and should not be used to guide empirical antibiotic therapy for SAB. A positive prior MRSA screening swab greatly increases likelihood of MRSA, necessitating MRSA coverage in empirical antibiotic therapy for SAB.
An open-label, pragmatic, randomized controlled clinical trial to evaluate the comparative effectiveness of daptomycin versus vancomycin for the treatment of complicated skin and skin structure infection.
BMC Infect Dis. 2015 Nov 7;15:503.
Kauf TL1, McKinnon P2, Corey GR3, Bedolla J4, Riska PF5, Sims M6, Jauregui-Peredo L7, Friedman B8, Hoehns JD9, Mercier RC10, Garcia-Diaz J11, Brenneman SK12, Ng D13, Lodise T14.
1Health Economics and Outcomes Research, Merck & Co., Inc., 2000 Galloping Road, Kenilworth, NJ, 07033, USA. email@example.com
2Global Center for Scientific Affairs, Merck Research Laboratories, Merck & Co., Inc, Kenilworth, NJ, USA. firstname.lastname@example.org
3Department of Medicine, Duke University Health System, Durham, NC, USA. email@example.com
4University of Texas at Austin Dell Medical School, Austin, TX, USA. firstname.lastname@example.org
5Albert Einstein College of Medicine Montefiore Medical Center, Bronx, NY, USA. email@example.com
6Infectious Diseases Research, William Beaumont Hospital, Royal Oak, MI, USA. firstname.lastname@example.org
7Medical Research, Mercy Saint Vincent Medical Center, Toledo, OH, USA. email@example.com
8JM Still Burn Center at Doctors Hospital, Augusta, GA, USA. firstname.lastname@example.org
9Northeast Iowa Medical Education Foundation, Waterloo, IA, USA. email@example.com
10Pharmacy and Medicine, University of New Mexico, Albuquerque, NM, USA. firstname.lastname@example.org
11Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, LA, USA. email@example.com
12Health Economics and Outcomes Research, Optum, Eden Prairie, MN, USA. firstname.lastname@example.org
13Department of Emergency Medicine, Nassau University Medical Center, East Meadow, NY, USA. email@example.com
14Albany College of Pharmacy and Health Sciences, Albany, NY, USA. firstname.lastname@example.org
Treatment of complicated skin and skin structure infection (cSSSI) places a tremendous burden on the health care system. Understanding relative resource utilization associated with different antimicrobials is important for decision making by patients, health care providers, and payers.
The authors conducted an open-label, pragmatic, randomized (1:1) clinical study (N=250) to compare the effectiveness of daptomycin with that of vancomycin for treatment of patients hospitalized with cSSSI caused by suspected or documented methicillin-resistant Staphylococcus aureus infection. The primary study end point was infection-related length of stay (IRLOS). Secondary end points included health care resource utilization, cost, clinical response, and patient-reported outcomes. Patient assessments were performed daily until the end of antibiotic therapy or until hospital discharge, and at 14 days and 30 days after discharge.
No difference was found for IRLOS, total LOS, and total inpatient cost between cohorts. Hospital LOS contributed 85.9 % to the total hospitalization cost, compared with 6.4 % for drug costs. Daptomycin showed a nonsignificant trend toward a higher clinical success rate, compared with vancomycin, at treatment days 2 and 3. In the multivariate analyses, vancomycin was associated with a lower likelihood of day 2 clinical success (odds ratio [OR]=0.498, 95 % confidence interval [CI], 0.249-0.997; P<0.05).
This study did not provide conclusive evidence of the superiority of one treatment over the other in terms of clinical, economic, or patient outcomes. The data suggest that physician and patient preference, rather than drug acquisition cost, should be the primary driver of initial antibiotic selection for hospitalized patients with cSSSI.
ClinicalTrials.gov: NCT01419184 (Date: August 16, 2011).