Inadequate Antimicrobial Treatment Research Articles

The real-world impact of the BioFire FilmArray blood culture identification 2 panel on antimicrobial stewardship among patients with bloodstream infections in intensive care units with a high burden of drug-resistant pathogens

BackgroundThe increasing prevalence of drug-resistant pathogens leads to delays in adequate antimicrobial treatment in intensive care units (ICU). The real-world influence of the BioFire FilmArray Blood Culture Identification 2 (BCID2) panel on pathogen identification, diagnostic concordance with conventional culture methods, and antimicrobial stewardship in the ICU remains unexplored. MethodsThis retrospective observational study, conducted from July 2021 to August 2023, involved adult ICU patients with positive blood cultures who underwent BCID2 testing. The concordance between BCID2 and conventional culture results was examined, and its impact on antimicrobial stewardship was assessed through a comprehensive retrospective review of patient records by intensivists. ResultsA total of 129 blood specimens from 113 patients were analysed. Among these patients, a high proportion of drug-resistant strains were noted, including carbapenem-resistant Klebsiella pneumoniae (CRKP) (57.1%), carbapenem-resistant Acinetobacter calcoaceticus-baumannii complex (100%), methicillin-resistant Staphylococcus aureus (MRSA) (70%), and vancomycin-resistant Enterococcus faecium (VRE) (100%). The time from blood culture collection to obtaining BCID2 results was significantly shorter than conventional culture (46.2 h vs. 86.9 h, p < 0.001). BCID2 demonstrated 100% concordance in genotype–phenotype correlation in antimicrobial resistance (AMR) for CRKP, carbapenem-resistant Escherichia coli, MRSA, and VRE. A total of 40.5% of patients received inadequate empirical antimicrobial treatment. The antimicrobial regimen was adjusted or confirmed in 55.4% of patients following the BCID2 results. ConclusionsIn the context of a high burden of drug-resistant pathogens, BCID2 demonstrated rapid pathogen and AMR detection, with a noticeable impact on antimicrobial stewardship in BSI in the ICU.

Impact of inadequate empirical antibiotic treatment on outcome of non-critically ill children with bacterial infections

BackgroundThe impact of inadequate empirical antibiotic treatment on patient outcomes and hospitalization duration for non-life-threatening infections in children remains poorly understood. We aimed to assess the effects of inadequate empirical antibiotic treatment on these factors in pediatric patients.MethodsThe medical records of children admitted for infectious diseases with bacteria isolated from sterile sites between 2018 and 2020 were retrospectively reviewed. Patients who received adequate empirical treatment were compared with those who received inadequate treatment in terms of demographic, clinical, and laboratory variables.ResultsForty-eight patients who received inadequate empirical antimicrobial treatment were compared to 143 patients who received adequate empirical treatment. Inadequate empirical antimicrobial treatment did not significantly affect the length of hospital stay or the incidence of complications in non-critically ill children with bacterial infections. Younger age and underlying renal abnormalities were identified as risk factors for inadequate antimicrobial treatment, while associated bacteremia was more common in the adequate antimicrobial treatment group.Conclusionsinadequate antibiotic treatment did not affect the outcomes of non-critically ill children with bacterial infectious diseases. Therefore, routine empirical broad-spectrum treatment may not be necessary for these cases, as it can lead to additional costs and contribute to antibiotic resistance. Larger prospective studies are needed to confirm these findings.

Gastric microbiome changes in relation with Helicobacter pylori resistance.

Inadequate antimicrobial treatment has led to multidrug-resistant (MDR) bacteria, including Helicobacter pylori (H. pylori), which one of the notable pathogens in the stomach. Antibiotic-induced changes in the microbiota can negatively affect the host. This study aimed to determine the influence of H. pylori resistance on the diversity and abundance of the stomach microbiome. Bacterial DNA was extracted from biopsy samples of patients presenting dyspepsia symptoms with H. pylori positive from cultures and histology. DNA was amplified from the V3-V4 regions of the 16S rRNA gene. In-vitro E-test was used to detect antibiotic resistance. Microbiome community analysis was conducted through α-diversity, β-diversity, and relative abundance. Sixty-nine H. pylori positive samples were eligible after quality filtering. Following resistance status to five antibiotics, samples were classified into 24 sensitive, 24 single resistance, 16 double resistance, 5 triple resistance. Samples were mostly resistant to metronidazole (73.33%; 33/45). Comparation of four groups displayed significantly elevated α-diversity parameters under the multidrug resistance condition (all P <0.05). A notable change was observed in triple-resistant compared to sensitive (P <0.05) and double-resistant (P <0.05) groups. Differences in β-diversity by UniFrac and Jaccard were not significant in terms of the resistance (P = 0.113 and P = 0.275, respectively). In the triple-resistant group, the relative abundance of Helicobacter genera was lower, whereas that of Streptococcus increased. Moreover, the linear discriminant analysis effect size (LEfSe) was associated with the presence of Corynebacterium and Saccharimonadales in the single-resistant group and Pseudomonas and Cloacibacterium in the triple-resistant group. Our results suggest that the resistant samples showed a higher trend of diversity and evenness than the sensitive samples. The abundance of H. pylori in the triple-resistant samples decreased with increasing cohabitation of pathogenic bacteria, which may support antimicrobial resistance. However, antibiotic susceptibility determined by the E-test may not completely represent the resistance status.

Analysis of Potential Risk Factors for Multidrug-Resistance at a Burn Unit

Background: Infections by multidrug-resistant (MDR) microorganisms are associated with increased morbidity and mortality in burn patients. This study aimed to analyze the evolution of MDR bacteria over a five-year period at Coimbra Burns Unit (CBU) in Portugal, seeking to assess the possible associations of specific bacteria with presumed risk factors. Methods: The data obtained consisted of identified bacteria present in any microbiological sample from each patient (including blood, central venous catheter, urine, tracheal aspirate and/or wound exudate). Univariate models and a multivariate model were constructed for each of the MDR bacteria species that infected at least 50 patients or that had five or more MDR strains. Statistical hypothesis tests with a p-value less than 0.05 were considered significant. Results: Of a total of 341 samples obtained, 107 were MDR, corresponding to 10 species. Globally, there was no significant variation in MDR bacteria frequency over the period under analysis. Some risk factors and/or trends were identified for some species, but none was linked to all of them. Conclusions: The risks for the development of MDR in bacteria in burn patients are multifactorial, mainly linked to longer hospital stays, the use of invasive devices and inadequate antimicrobial treatment. However, the influence of these risks regarding specific bacterial species is not straightforward and may rely on individual characteristics, type of treatment and/or local prevalent flora. Due to the severity of multidrug-resistant infections, continued microbiological surveillance with the aid of rapid diagnostic tests and prompt institution of appropriate antimicrobial therapy are crucial to improving outcomes for burn patients.

Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry (MALDI-TOF MS) for the Identification of Bacteria Causing Urinary Tract Infections

Background: Matrix assisted laser desorption/ionization-time of flight (MALDI-TOF) technology is a technique which allows microbial identification in clinical microbiology laboratories based on microbial protein profiles. A promising application of the MALDI-TOF technique comprises carrying out identification from direct urine samples. Objectives: The aim of this study is to evaluate the performance of MALDI-TOF MS system for the rapid identification of clinically relevant urinary tract pathogens in urine samples to the species level. Methodology: two hundred (200) urine samples with findings suggestive of urinary tract infections (UTI) were identified directly by MALDI-TOF MS, and same samples were identified from culture on MALDI-TOF MS. 73 colonies from 73 samples were further identified by Bd Phoneix and PCR. Results: MALDI-TOF MS directly from samples identified 174 samples (91 to the species level 83 to genus level), while MALDI-TOF MS after culture identified 191 samples (187 to the level of species, and 4 to genus level). In addition, 9 samples gave no results from the direct method and no growth in culture. The sensitivity and specificity of direct method compared to after culture method was 91.1% and 100%, respectively. Colonies of 73 samples were detected by the BD Phoneix automated identification system and by PCR. The results were identical among the three systems. Conclusion: The ability of MALDI-TOF MS’s to detect microorganisms from urine samples directly can provide early diagnosis of UTIs and avoid the inadequate or unnecessary empirical antimicrobial treatment.

Pseudomonas aeruginosa in Bronchiectasis.

Pseudomonas aeruginosa (PA) in patients with bronchiectasis (BE) is associated with a poor outcome and quality of life, and its presence is considered a marker of disease severity. This opportunistic pathogen is known for its ability to produce biofilms on biotic or abiotic surfaces and to survive environmental stress exerted by antimicrobials, inflammation, and nutrient or oxygen depletion. The presence of PA biofilms has been linked to chronic respiratory infection in cystic fibrosis but not in BE. There is considerable inconsistency in the reported infection/eradication rates of PA and chronic PA. In addition, inadequate antimicrobial treatment may potentiate the progression from intermittent to chronic infection and also the emergence of antibiotic resistance. A better comprehension of the pathophysiology of PA infections and its implications for BE is urgently needed. This can drive improvements in diagnostic accuracy, can move us toward a new consensus definition of chronic infection, can better define the follow-up of patients at risk of PA, and can achieve more successful eradication rates. In addition, the new technological advances regarding molecular diagnostics, -omics, and biomarkers require us to reconsider our traditional concepts.

Hypoalbuminemia as Surrogate and Culprit of Infections.

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

Characterization of multidrug-resistant avian pathogenic Escherichia coli: an outbreak in canaries.

The canary (Serinus canaria) is appreciated for its beautiful song, colors, and docile temperament and drives a lucrative business. However, diseases caused by avian pathogenic Escherichia coli (APEC) compromise the health of canaries, and the inadequate antimicrobial treatment can lead to the emergence of resistant strains. This study aimed to characterize 21 isolates of E. coli obtained from canaries infected with colibacillosis during an outbreak in northern Paraná State, Brazil. APEC and diarrheagenic E. coli (DEC) virulence genes were screened for by polymerase chain reaction (PCR). All isolates were positive for the hlyF, iss, and ompT genes, which are characteristic of APEC. The iroN gene was found in 95.2% of isolates, and none had the iutA gene. The ipaH gene, characteristic of enteroinvasive E. coli (EIEC), was found in 71.4% of isolates, all belonging to the phylogenetic group B1. High genetic similarity (>95%) was found using enterobacterial repetitive intergenic consensus PCR (ERIC-PCR). The isolates belonged to serotypes O117:H4 (71.4%) and O1:H20 (23.8%). This is the first report of a clonal colibacillosis outbreak in canaries caused by APEC. All isolates were resistant to ampicillin, nalidixic acid, ciprofloxacin, enrofloxacin, norfloxacin, and tetracycline. The high rate of multidrug resistance in our study shows the importance of avoiding the inadequate antibiotic treatment. We suggest that further studies should be conducted to contribute to the understanding of colibacillosis in canaries since the health of animals is linked to human and environmental health, as defined by the concept of One Health.

Trauma and Antimicrobial Resistance Are Independent Predictors of Inadequate Empirical Antimicrobial Treatment of Ventilator-Associated Pneumonia in Critically Ill Patients.

Background: We aimed to assess independent risk factors for inadequate initial antimicrobial treatment (IAT) in critically ill patients with ventilator-associated pneumonia (VAP) treated in intensive care units (ICU) and to determine whether IAT is associated with adverse outcomes in patients with VAP. Patients and Methods: A prospective cohort study was performed and included 152 patients with VAP treated in an ICU for more than 48 hours. The main outcomes of interest were all-cause ICU mortality and VAP-related mortality. Other outcomes considered were: intra-hospital mortality, VAP-related sepsis, relapse, re-infection, length of stay in ICU (ICU LOS), and number of days on mechanical ventilation (MV). Results: One-third of patients (35.5%) received inadequate antimicrobial therapy. Trauma (odds ratio [OR], 3.55; 95% confidence interval [CI], 1.25-10.06) and extensively drug-resistant (XDR) causative agent (OR, 3.09; 95% CI, 1.23-7.74) were independently associated with inadequate IAT. Inadequate IAT was associated with a higher mortality rate (OR, 3.08; 95% CI, 1.30-7.26), VAP-related sepsis (OR, 2.39; 95% CI, 1.07-5.32), relapse (OR, 3.25; 95% CI, 1.34-7.89), re-infection (OR, 6.06; 95% CI, 2.48-14.77), and ICU LOS (β 4.65; 95% CI, 0.93-8.36). Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella/Enterobacter spp. were the most common bacteria in patients with IAT and those with adequate antimicrobial therapy. Conclusions: This study demonstrated that inadequate IAT is associated with a higher risk of the majority of adverse outcomes in patients with VAP treated in ICUs. Trauma and XDR strains of bacteria are independent predictors of inadequate IAT of VAP in critically ill patients.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology.

IntroductionDestructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors.MethodsEighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality.ResultsThirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients.ConclusionIn endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Bacterial membrane vesicles from Acinetobacter baumannii induced by ceftazidime are more virulent than those induced by imipenem

ABSTRACT Patients with Acinetobacter baumannii bacteremia treated with antipseudomonal cephalosporins showed higher 14-day mortality than patients treated with antipseudomonal carbapenems. We hypothesized that the bacterial membrane vesicles (BMVs) induced by antipseudomonal cephalosporins are more virulent than BMVs induced by antipseudomonal carbapenems. To simulate the clinical condition with inadequate antimicrobial treatment, carbapenem-resistant A. baumannii was treated with ceftazidime (an antipseudomonal cephalosporin) or imipenem (an antipseudomonal carbapenem) at 1/2 the minimum inhibitory concentration. BMVs and BMV-carried lipopolysaccharide were measured by nanoparticle tracking analysis and western blotting, respectively. Cytokine expression in RAW264.7 macrophages or mice serum induced by the BMVs was determined by ELISA, fluorescent bead-based immunoassay or western blotting. The virulence of the BMVs was assessed in mice. Liquid chromatography tandem-mass spectrometry was used to determine the protein contents of the BMVs. We found that ceftazidime induced a higher number of BMVs (CAZ-BMV), which carried more LPS, and induced higher expression levels of iNOS, IL-1β, and IL-6 in macrophages, higher expression of many cytokines in mice, more neutrophil infiltration in lung interstitium, and higher mortality in mice than imipenem-induced BMVs (IMP-BMV). When adjusted to same amount of LPS, CAZ-BMV still led to higher mortality than IMP-BMV. Proteomic analysis revealed different protein contents in CAZ-BMV and IMP-BMV. In conclusion, A. baumannii BMVs induced by ceftazidime are more virulent than BMVs induced by imipenem.

Characteristics of febrile urinary tract infections in older male adults

BackgroundUrinary tract infections (UTI) are among the most frequent bacterial infections in older adults. The aim of the study was to analyse the existence of differences in clinical features, microbiological data and risk of infection by multidrug-resistant organisms (MDRO) between older and non-older men with febrile UTI (FUTI).MethodsThis was an ambispective observational study involving older males with a FUTI attended in the Emergency Department. Variables collected included age, comorbidity, diagnostic of healthcare-associated (HCA)-FUTI, clinical manifestations, hospitalization, mortality, and microbiological data.ResultsFive hundred fifty-two males with a FUTI, 329 (59.6%) of whom were older adults, were included. Older males had a higher frequency of HCA-FUTI (p < 0.001), increased Charlson scores (p < 0.001), had received previous antimicrobial treatment more frequently (p < 0.001) and had less lower urinary tract symptoms (p < 0.001). Older patients showed a lower frequency of FUTI caused by E. coli (p < 0.001) and a higher rate of those due to Enterobacter spp. (p = 0.003) and P. aeruginosa (p = 0.033). Resistance rates to cefuroxime (p = 0.038), gentamicin (p = 0.043), and fluoroquinolones (p < 0.001) in E. coli isolates and the prevalence of extended-spectrum beta-lactamase and AmpC producing E. coli and Klebsiella spp. strains (p = 0.041) and MDRO (p < 0.001) were increased in older males. Inadequate empirical antimicrobial treatment (p = 0.004), frequency of hospitalization (p < 0.001), and all cause in-hospital mortality (p = 0.007) were higher among older patients. In the multivariate analysis, being admitted from an long term care facility (OR 2.4; 95% CI: 1.06–5.9), having a urinary tract abnormality (OR 2.2; 95% CI: 1.2–3.8) and previous antimicrobial treatment (OR 3.2; 95% CI: 1.9–5.4) were associated to FUTI caused by MDRO.ConclusionsOlder male adults with a FUTI have different clinical characteristics, present specific microbiological features, and antimicrobial resistance rates. In the multivariate analysis being an older male was not associated with an increased risk of FUTI caused by MDRO.

The clinical impact of Stenotrophomonas maltophilia bacteremia on the 30-day mortality rate in patients with hematologic disorders: a single-institution experience.

Stenotrophomonas maltophilia (SM) is an important nosocomial pathogen, particularly in immunocompromised patients due to their adverse antimicrobial susceptibility pattern. The objective of this article was to investigate the clinical impact of SM bacteremia on the 30-day mortality rate and identify the risk factors of the cause of mortality in patients with hematologic disorders. We retrospectively reviewed the clinical data in patients diagnosed with hematological disorders and SM bacteremia over an 8-year period from July 2010 to July 2018 at a 248-bed hematology department. We compared patients' clinical characteristics and outcomes between the non-survivor and survivor groups. The overall incidence of SM bacteremia was 25.1 per 10,000 admissions. There were 59 patients (median age: 35 years; 57.6% males) included in the study with an overall SM bacteremia-related 30-day mortality of 44.1%. Multi-drug resistance was common. In vitro susceptibility is higher to ceftazidime (72.9%), ciprofloxacin (66.1%) and cefoperazone/sulbactam (59.3%). The risk factors identified in the univariate analysis were catheter re-implantation, accompanying polymicrobial infection, inadequate initial antimicrobial treatment, APACHE II score, temperature > 39°C, septic shock, respiratory failure, and non-remission post treatment for primary diseases. Multivariate analysis further confirmed that inadequate initial antimicrobial treatment, respiratory failure, and non-remission after treatment for hematological diseases are independent risk factors associated with mortality (P=0.001, 0.002 and 0.007, respectively). Our study suggests that SM bacteremia is highly associated with increased mortality in patients with hematologic diseases. Early detection, prompt comprehensive management including initiation of combined sensitive antibiotics, respiratory monitoring and support, platelet infusion, and strategies to improve patients' remission status are recommended to improve the overall survival in patients with SM bacteremia.

Inadequate empirical antimicrobial treatment in older people with bacteremic urinary tract infection who reside in nursing homes: A multicenter prospective observational study.

The aim of the study was to determine the rate of inadequate empirical antimicrobial treatment in older nursing home residents with bacteremic urinary tract infection and its influence on prognosis. We carried out a multicentric prospective observational study in five Spanish hospitals. Patients aged >65 years with pyelonephritis or urinary sepsis with bacteremia were included. Clinical characteristics, the percentage of inadequate empirical antibiotic treatment, length of hospital stay and mortality were evaluated. A total of 181 patients, 54.7% women, were included in the study, and 35.9% of the patients came from nursing homes. These patients had higher percentages of ultimately or rapidly fatal disease (92.3% vs 53.4%; P < 0.001), were older (83.15 ± 6.97 years vs 79.34 ± 7.25 years; P = 0.001) and had higher Acute Physiology And Chronic Health Evaluation II (28.38 ± 8.57 vs 19.83 ± 5.88). The percentage of extended-spectrum beta-lactamases was higher in patients from nursing homes (30.6% vs 16.3%; P = 0.045), as was the percentage of inadequate empirical antibiotic treatment (40% vs 20.7%; P = 0.005). Length of hospital stay was longer (10.82 ± 3.62 days vs 9.04 ± 4.88 days; P < 0.001). However, 30-day mortality was not related to nursing home by multivariate analysis (OR 1.905, 95% CI 0.563-6.446; P = 0.300). Nursing home patients with bacteremic urinary tract infections had a higher rate of extended-spectrum beta-lactamase-producing enterobacteriacea and inadequate empirical antimicrobial treatment. Clinicians should consider these findings and avoid inappropriate antimicrobial agents for empirical treatment. Geriatr Gerontol Int 2019; 19: 1112-1117.

Antimicrobial treatment practices among Ugandan children with suspicion of central nervous system infection.

Acute central nervous system (CNS) infections in children in sub-Saharan Africa are often fatal. Potential contributors include late presentation, limited diagnostic capacity and inadequate treatment. A more nuanced understanding of treatment practices with a goal of optimizing such practices is critical to prevent avoidable case fatality. We describe empiric antimicrobial treatment, antibiotic resistance and treatment adequacy in a prospective cohort of 459 children aged two months to 12 years hospitalised for suspected acute CNS infections in Mbarara, Uganda, from 2009 to 2012. Among these 459 children, 155 had a laboratory-confirmed diagnosis of malaria (case-fatality rate [CFR] 14%), 58 had bacterial infections (CFR 24%) and 6 children had mixed malaria and bacterial infections (CFR 17%). Overall case fatality was 18.1% (n = 83). Of 219 children with laboratory-confirmed malaria and/or bacterial infections, 182 (83.1%) received an adequate antimalarial and/or antibiotic on the day of admission and 211 (96.3%) within 48 hours of admission. The proportion of those receiving adequate treatment was similar among survivors and non-survivors. All bacterial isolates were sensitive to ceftriaxone except one Escherichia coli isolate with extended-spectrum beta-lactamase (ESBL). The observed high mortality was not a result of inadequate initial antimicrobial treatment at the hospital. The epidemiology of CNS infection in this setting justifies empirical use of a third-generation cephalosporin, however antibiotic resistance should be monitored closely.

Masked mastoiditis with meningitis : do we treat ct scan?

Otogenic infection is the most common cause of meningitis.Therefore, it should be ruled out during clinical assessment of a patient with any intracranial infection. Masked mastoiditis is a known intratemporal complication of acute otitis media after inadequate antimicrobial treatment. It is defined as inflammation of mucosal lining and bony structures of the mastoid air cells with an intact tympanic membrane. It should be regarded as the source of infection in a patient with meningitis and positive radiological findings of mastoiditis even though the patient does not have any evidence of ear infection clinically. We report a case of bacterial meningitis following masked mastoiditis in an 68-years-old man.Bangladesh Journal of Medical Science Vol.16(3) 2017 p.458-460

Predictors of mortality in bloodstream infections caused by multidrug-resistant gram-negative bacteria: 4 years of collection.

The study was undertaken to describe the profile of patients and the characteristics of all multidrug-resistant gram-negative bacteria (MDR-GNB) and to assess mortality. We examined 138 patients with bloodstream infections (BSIs) caused by MDR-GNB. Clinical characteristics, antibiotic therapy, and in-hospital mortality were analyzed. Survivor and nonsurvivor subgroups were compared to identify predictors of mortality. The in-hospital mortality rate was 25.4%. Univariate analysis revealed that comorbidities and inadequate initial antimicrobial treatment could increase risk of death. In Cox regression analysis, mortality was independently associated with the age (P = .034), hospitalization in an intensive care unit (ICU) (P = .04), invasive procedures (P < .001), and Acute Physiology and Chronic Health Evaluation II scores (P < .001), whereas combination therapy or monotherapy was not associated with mortality (P = .829). Postantibiogram therapy was associated with hospitalization in an ICU (P = .006), Charlson comorbidity index score (P = .003), and inadequate initial antimicrobial treatment (P < .001). MDR-GNB strains and antimicrobial regimens were not the major risk factors of mortality. Inadequate initial antimicrobial treatment, invasive procedures, high Acute Physiology And Chronic Health Evaluation II scores, hospitalization in an ICU, and comorbidities were the important factors responsible for mortality. Although there was no difference between combination therapy and monotherapy in mortality, combined treatment may be more effective than monotherapy for patients in an ICU, with a Charlson comorbidity index score < 4, or inadequate initial antimicrobial treatment.

The Effect of Inadequate Initial Empiric Antimicrobial Treatment on Mortality in Critically Ill Patients with Bloodstream Infections: A Multi-Centre Retrospective Cohort Study.

Hospital mortality rates are elevated in critically ill patients with bloodstream infections. Given that mortality may be even higher if appropriate treatment is delayed, we sought to determine the effect of inadequate initial empiric treatment on mortality in these patients. A retrospective cohort study was conducted across 13 intensive care units in Canada. We defined inadequate initial empiric treatment as not receiving at least one dose of an antimicrobial to which the causative pathogen(s) was susceptible within one day of initial blood culture. We evaluated the association between inadequate initial treatment and hospital mortality using a random effects multivariable logistic regression model. Among 1,190 patients (1,097 had bacteremia and 93 had candidemia), 476 (40%) died and 266 (22%) received inadequate initial treatment. Candidemic patients more often had inadequate initial empiric therapy (64.5% versus 18.8%), as well as longer delays to final culture results (4 vs 3 days) and appropriate therapy (2 vs 0 days). After adjustment, there was no detectable association between inadequate initial treatment and mortality among bacteremic patients (Odds Ratio (OR): 1.02, 95% Confidence Interval (CI) 0.70–1.48); however, candidemic patients receiving inadequate treatment had nearly three times the odds of death (OR: 2.89, 95% CI: 1.05–7.99). Inadequate initial empiric antimicrobial treatment was not associated with increased mortality in bacteremic patients, but was an important risk factor in the subgroup of candidemic patients. Further research is warranted to improve early diagnostic and risk prediction methods in candidemic patients.

The Effect of Inadequate Initial Antimicrobial Treatment on Mortality in Critically Ill Patients With Bloodstream Infections

The Effect of Inadequate Initial Antimicrobial Treatment on Mortality in Critically Ill Patients With Bloodstream Infections

Differential characteristics of healthcare-associated compared to community-acquired febrile urinary tract infections in males.

The objective of this study was to analyse the characteristics of healthcare-associated febrile urinary tract infection (HCA-FUTI) compared to community-acquired FUTI (CA-FUTI) in men. An ambispective cross-sectional study in which we recorded clinical and microbiology data and outcomes from males with FUTI attended in the Emergency Department was carried out. A total of 479 males with FUTI, 162 (33.8%) HCA-FUTI and 317 (66.2%) CA-FUTI, were included. HCA-FUTI patients were older (p < 0.001), had higher Charlson scores (p < 0.001) and received previous antimicrobial treatment more frequently (p < 0.001) compared to CA-FUTI patients. HCA-FUTI was less likely caused by Escherichia coli (p < 0.001) and more frequently by Klebsiella spp. (p = 0.02), Enterobacter spp. (p < 0.001) and Pseudomonas aeruginosa (p < 0.001). Resistance to ceftriaxone (p = 0.006), gentamicin (p < 0.001), quinolones (p < 0.001), co-trimoxazole (p = 0.001) and fosfomycin (p = 0.009) was higher among E. coli strains isolated from males with HCA-FUTI and so was the prevalence of extended-spectrum beta-lactamase and AmpC E. coli and Klebsiella spp.-producing strains (p = 0.012). Inadequate antimicrobial treatment and all-cause in-hospital mortality was associated with HCA-FUTI (p < 0.001 and p = 0.004, respectively). Independent factors for mortality were severe sepsis or septic shock [odds ratio (OR) 29; 95% confidence interval (CI): 3.9-214] and cirrhosis (OR 23.7; 95% CI: 1.6-350.6). Male patients with HCA-FUTI have different clinical characteristics, outcomes and microbiological features compared to CA-FUTI patients. Previous contact with the healthcare system has to be taken into consideration when deciding the optimal antimicrobial treatment in males with FUTI.