Novel surface biochemical modifications of urinary catheters to prevent catheter-associated urinary tract infections.

More than 70% of hospital-acquired urinary tract infections are related to urinary catheters, which are commonly used for the treatment of about 20% of hospitalized patients. Urinary catheters are used to drain the bladder if there is an obstruction in the tube that carries urine out of the bladder (urethra). During catheter-associated urinary tract infections, microorganisms rise up in the urinary tract and reach the bladder, and cause infections. Various materials are used to fabricate urinary catheters such as silicone, polyurethane, and latex. These materials allow bacteria and fungi to develop colonies on their inner and outer surfaces, leading to bacteriuria or other infections. Urinary catheters could be modified to exert antibacterial and antifungal effects. Although so many research have been conducted over the past years on the fabrication of antibacterial and antifouling catheters, an ideal catheter needs to be developed for long-term catheterization of more than a month. In this review, we are going to introduce the recent advances in fabricating antibacterial materials to prevent catheter-associated urinary tract infections, such as nanoparticles, antibiotics, chemical compounds, antimicrobial peptides, bacteriophages, and plant extracts.

[The use of a urethral catheter with an ultrasound-induced biopolymer drug coating for the prevention of recurrent bladder neck sclerosis in patients after endoscopic treatment of benign prostate hyperplasia].

Recurrent bladder neck sclerosis is one of the common complications of endoscopic treatment of benign prostate hyperplasia, which often leads to multiple re-operations, including complex open and laparoscopic reconstructive procedures. One of the most promising minimally invasive methods for preventing recurrence of bladder neck sclerosis is balloon dilatation under transrectal ultrasound guidance. To improve the results of using this technique, a urethral catheter with a biopolymer coating, capable of depositing a drug and eluting it under the influence of diagnostic ultrasound, was proposed.

[Prevention of the development of catheter-associated urinary system infections in the early postoperative period].

BACKGROUND: Bladder catheterization is a common medical manipulation that is associated with the risk of complications, including catheter-associated urinary tract infection (CAUTI), which accounts for 80% of all nosocomial infections of the urological profile. AIM: To evaluate the combined use of the biologically active additive Uronext and ceftriaxone in the prevention of the development of CAUTI in the early postoperative period in 120 patients aged 20-80 years with a Foley indwelling catheter. MATERIALS AND METHODS: The patients were divided into 2 groups: in group I (n=60), D-mannose with cranberry extract and vitamin D3 as part of Uronext dietary supplement was administered orally in the form of sachets 48 hours before surgery and after surgery until urethral catheter was placed, as well as intravenous ceftriaxone 1000 mg 2 hours before surgery and in the postoperative period within 7 days. In group II (n=60), ceftriaxone monotherapy was prescribed in a similar way. RESULTS: According to the results of bacteriological examination of the removed urinary catheter on 3-7 days in Uronext group, bacterial growth was absent in 40 patients (66.67%, p<0.05), versus 23 cases (38.33%) in the control group. CONCLUSIONS: The data obtained confirm the efficiency of the use of the biologically active additive Uronext in combination with an antibacterial drug, which allows to recommend this scheme in patients with an indwelling urinary catheter for the prevention of the development of CAUTI.

Efficacy of organo-selenium-incorporated urinary catheter tubing for in vitro growth inhibition of E. coli, K. pneumoniae, P. aeruginosa, and H. influenzae.

PURPOSE: Catheter-associated urinary tract infections are of significant medical burden in cost, morbidity, and mortality. Experimental selenium-coated medical devices have demonstrated non-toxic in vitro and in vivo antimicrobial activity. While antimicrobial-coated catheters have shown efficacy in preventing CAUTIs, selenium has not been tested in this context. The purpose of this in vitro study is to evaluate selenium-incorporated urinary catheters for inhibition of uropathogenic bacterial growth and biofilm formation. METHODS: Urinary catheters incorporated with 1% organo-selenium and standard (uncoated) catheters were incubated in vitro with E. coli, K. pneumoniae, P. aeruginosa, H. influenzae, and combinations of these bacteria. Growth was evaluated by colony-forming unit count and visualized with confocal laser and scanning electron microscopy. Organo-selenium catheter material integrity was also tested by soaking the tubing in phosphate-buffered saline for 12 weeks at 37 °C. RESULTS: Organo-selenium-incorporated catheters demonstrated total reduction (100%) of in vitro bacterial growth and biofilm formation for E. coli, K. pneumoniae, H. influenzae, and a combination of these species when compared to control. P. aeruginosa growth was inhibited by approximately 4 logs (99.99%). Complete inhibition of E. coli growth was maintained after long-term phosphate-buffered saline soaking. CONCLUSION: The results demonstrate that organo-selenium was stably incorporated into catheter tubing and inhibited bacterial attachment, growth, and biofilm formation for multiple uropathogenic organisms. Furthermore, long-term soaking of organo-selenium tubing in phosphate-buffered saline did not show any decline in bacterial growth inhibition or biofilm formation. These findings suggest that organo-selenium-incorporated catheters may be advantageous in preventing catheter-associated urinary tract infections and warrant further in vivo and clinical evaluation.

Urinary Outcomes After Magnetic Resonance Imaging-Guided Whole-Gland Transurethral Ultrasound Ablation for Prostate Cancer: Comparison of Suprapubic Tube to Indwelling Urethral Catheter.

Background: MRI-guided transurethral ultrasound ablation (TULSA) is under investigation for whole-gland ablation of low- and intermediate-risk prostate cancer. The ideal method for post-TULSA bladder drainage through postoperative suprapubic tube (SPT) vs indwelling urethral catheter (UC) has not been established. The objective of this study was to evaluate urinary outcomes after whole-gland TULSA, comparing postoperative SPT with UC. Materials and Methods: Two-institution retrospective analysis of whole-gland TULSA for men with grade group 1 and 2 prostate cancer. One institution placed SPT at the time of TULSA with clamp trials (day 10) and removal once voiding. The second placed UC until void trial (day 7). Outcomes included the International Prostate Symptom Score (IPSS), urinary bother score, catheter reinsertion, stricture, clean intermittent catheterization (CIC), and incontinence. Results: Forty-five patients (median age 67) were analyzed. The UC cohort (N = 26) was older (p = 0.007) than the SPT cohort (N = 19) but with similar baseline prostate volumes, IPSS, and urinary bother scores. Patients receiving UC had fewer days with catheter (p = 0.013). Although UC patients suffered more lower urinary tract symptoms at 1-month post-TULSA, there was no significant difference between IPSS scores at baseline and 6 months after surgery regardless of urinary management strategy, although the UC group noted significantly decreased urinary bother. Rates of infection were similar between groups. Six strictures were observed overall, with more in the SPT group, although the difference was not significant (4/19 [21.1%] SPT; 2/26 [7.7%] UC). At 6 months, incontinence rates were low and similar between groups (2/19 [10.5%] SPT; 4/26 [15.4%] UC) and only one patient (UC) required CIC. Conclusions: Our overall findings suggest that SPT and UC are both acceptable options for postoperative bladder drainage after whole-gland TULSA, with statistically similar rates of urinary complications but a slightly different side effect profile.

Single-dose intravenous nefopam on postoperative catheter-related bladder discomfort in patients undergoing transurethral resection of prostate: a randomized, double-blind placebo-controlled trial.

PURPOSE: Transurethral resection of prostate (TURP) with postoperative catheter traction can lead to significant catheter-related bladder discomfort (CRBD). This condition causes many postoperative complications and low patient satisfaction. This study aimed to evaluate the effectiveness of preoperative single-dose intravenous nefopam on the incidence and severity of CRBD and its adverse effects. METHODS: This randomized, controlled, double-blind study included patients who underwent TURP under spinal anesthesia with postoperative urinary catheter traction. Patients were allocated into nefopam (NF) and normal saline (NS) groups. Twenty mg of nefopam in normal saline solution (NSS) 100 mL or NSS 100 mL were given intravenously before TURP. The primary outcome was the incidence of CRBD. RESULTS: Seventy-three patients were randomized into NF (n = 37) and NS (n = 36) groups. There were 35 and 33 patients in the NF and NS groups, respectively, in the final analysis. The incidences of CRBD were 45.71% and 84.85% in the NF and NS groups at 6 h after operation, respectively, OR 0.54 (95% CI 0.36, 0.73), while before the end of catheter traction, the corresponding incidences were 37.14% and 75.76%, respectively, OR 0.49 (95% CI 0.28, 0.84). The CRBD scores were statistically significantly lower in the NF group at both time points. Morphine consumptions and adverse effects were not different between groups. Patient satisfaction was higher in the NF group. CONCLUSIONS: Single-dose nefopam significantly reduced the incidence and severity of CRBD in patients undergoing TURP with urinary catheter traction at 6 h after the procedure and before the end of catheter traction without increasing the adverse effects.

Development of a Hemostatic Urinary Catheter for Transurethral Prostatic Surgical Applications.

OBJECTIVE: To investigate a novel transurethral hemostatic catheter device with an integrated chitosan endoluminal hemostatic dressing (CEHD). Development and implementation of this technology may help address bleeding following surgery such as transurethral resection of prostate (TURP). Bleeding remains the most common complication following TURP, leading to increased morbidity and hospitalization. METHODS: Investigation of hemostasis, delivery, safety and efficacy of the CEHD device is conducted using Female Yorkshire swine (N = 23). Hemostatic efficacy of the CEHD (N = 12) is investigated against a control of gauze (N = 12) in a splenic injury model (3 swine). The delivery, safety, and efficacy of the CEHD device (N = 10) are investigated against Foley-catheter control (N = 10) for 7 days using a swine bladder-neck-injury model. RESULTS: In the splenic injury study, 9/12 CEHD dressings successfully achieved hemostasis within 150 seconds (mean 83 seconds) vs success of 6/12 (mean 150 seconds) for gauze (P = .04). In the 7-day study, the CEHD was successfully deployed in 10/10 animals and all dressings were tolerated without histologic or clinical adverse effect. Hemostasis of the CEHD device was found to be noninferior to control catheters. Noninferiority is attributed to low bleeding rates in the swine bladder neck injury model. CONCLUSION: This investigation successfully demonstrated the feasibility of transurethral deployment of the CEHD in vivo. Routine use of safe and slowly dissolvable CEHDs could reduce the rate of complications and hospitalizations associated with bleeding and blood loss in TURP procedures. Further investigation is warranted.

Sonochemically engineered nano-enabled zinc oxide/amylase coatings prevent the occurrence of catheter-associated urinary tract infections.

Catheter-associated urinary tract infections (CAUTIs), caused by biofilms, are the most frequent health-care associated infections. Novel antibiofilm coatings are needed to increase the urinary catheters' life-span, decrease the prevalence of CAUTIs and reduce the development of antimicrobial resistance. Herein, antibacterial zinc oxide nanoparticles (ZnO NPs) were decorated with a biofilm matrix-degrading enzyme amylase (AM) and simultaneously deposited onto silicone urinary catheters in a one-step sonochemical process. The obtained nano-enabled coatings inhibited the biofilm formation of Escherichia coli and Staphylococcus aureus by 80% and 60%, respectively, for up to 7 days in vitro in a model of catheterized bladder with recirculation of artificial urine due to the complementary mode of antibacterial and antibiofilm action provided by the NPs and the enzyme. Over this period, the coatings did not induce toxicity to mammalian cell lines. In vivo, the nano-engineered ZnO@AM coated catheters demonstrated lower incidence of bacteriuria and prevent the early onset of CAUTIs in a rabbit model, compared to the animals treated with pristine silicone devices. The nano-functionalization of catheters with hybrid ZnO@AM coatings appears as a promising strategy for prevention and control of CAUTIs in the clinic.

Bioengineered phytomolecules-capped silver nanoparticles using Carissa carandas leaf extract to embed on to urinary catheter to combat UTI pathogens.

Rising incidents of urinary tract infections (UTIs) among catheterized patients is a noteworthy problem in clinic due to their colonization of uropathogens on abiotic surfaces. Herein, we have examined the surface modification of urinary catheter by embedding with eco-friendly synthesized phytomolecules-capped silver nanoparticles (AgNPs) to prevent the invasion and colonization of uropathogens. The preliminary confirmation of AgNPs production in the reaction mixture was witnessed by the colour change and surface resonance plasmon (SRP) band at 410nm by UV-visible spectroscopy. The morphology, size, crystalline nature, and elemental composition of attained AgNPs were further confirmed by the transmission electron microscopy (TEM), selected area electron diffraction (SAED), X-ray diffraction (XRD) technique, Scanning electron microscopy (SEM) and energy dispersive spectroscopy (EDS). The functional groups of AgNPs with stabilization/capped phytochemicals were detected by Fourier-transform infrared spectroscopy (FTIR). Further, antibiofilm activity of synthesized AgNPs against biofilm producers such as Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa were determined by viability assays and micrographically. AgNPs coated and coating-free catheters performed to treat with bacterial pathogen to analyze the mat formation and disruption of biofilm formation. Synergistic effect of AgNPs with antibiotic reveals that it can enhance the activity of antibiotics, AgNPs coated catheter revealed that, it has potential antimicrobial activity and antibiofilm activity. In summary, C. carandas leaf extract mediated synthesized AgNPs will open a new avenue and a promising template to embed on urinary catheter to control clinical pathogens.

A randomised-controlled, prospective study on the effect of dorsal penile nerve block after TURP on catheter-related bladder discomfort and pain.

PURPOSE: In the present study, the impact of penile nerve block (PNB) on postoperative pain and Catheter-Related Bladder Discomfort (CRBD) in the transurethral resection of prostate(TURP) patients were evaluated. METHODS: Participants of the present study were selected from patients who performed TURP under spinal anaesthesia for benign prostatic hyperplasia (BPH) between January 2018 and July 2020. The present study was planned as a single-centre, randomised-controlled prospective study in which the patients were divided into two groups. Group 1 was administered Control (n:40), and Group 2 ultrasonography(USG) guided PNB (n:40). The patients were included in the Groups, respectively. Visual analogue scale (VAS) scores were questioned and recorded in order to evaluate the postoperative pain complaints of the patients after the operation. In addition, in order to evaluate the CRBD, VAS scores were questioned and recorded as 0th, 0-1th hour, 1st-2nd hour, 2nd-4th hour, 4th-8th hour, 8th-12th hour, and 12th-24th hour. In addition, postoperative pain and need for analgesic drug were recorded. Tramadol was given to patients with moderate to severe CRBD. The findings were compared between the Groups. RESULTS: There was no statistical difference demographic and per-operative data between Group 1 and Group 2. The CRBD and pain-related VAS scores were significantly higher in Group 1 between the 0 and 8th hours. There was no difference between VAS scores in the postoperative 8-24th hours. In total 24 hours, Group 2's need for tramadol was significantly less than Group 1. On examining the factors affecting CRBD in the multivariate analysis, age, body mass index(BMI), prostate volume, operation time do not affect CRBD statistically, and only PNB reduces CRBD (P: .029). While less drug-related complications were observed in Group 2, no serious complications related to PNB were observed. CONCLUSION: Penile nerve block is an effective method for the decrease pain and CRBD after urological surgery. It will also reduce the need for analgesics, and provide painless patients in the postoperative period.

Efficacy and Safety of Surgery for Benign Prostatic Obstruction in Patients with Preoperative Urinary Catheter.

Purpose: To evaluate the efficacy and safety of benign prostatic obstruction (BPO) surgery in patients with preoperative urinary catheterization. Patients and Methods: We conducted a multi-institutional retrospective study including all patients who failed a trial without catheter (TWOC) after acute urinary retention (AUR) between January 2017 and January 2019. Patients with neurogenic bladder, prostate cancer, or urethral stricture were excluded from the analysis. Patients underwent either monopolar/bipolar transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), prostate artery embolization (PAE), open prostatectomy (OP), or endoscopic enucleation. The primary endpoint was 12-month urinary catheter-free survival without using benign prostatic hyperplasia medications. Results: One hundred seventy-one consecutive men (median age: 71 years; median prostate volume: 75 cm3) underwent BPO surgery, including 48 (28%) TURP, 62 (36.3%) PVP, 21 (12.3%) endoscopic enucleation, 15 (8.8%) PAE, and 25 (14.6%) OP. The median duration of preoperative urinary catheterization was 69 days (interquartile range 46-125). The 12-month urinary catheter-free survival rate was 84.8% (145/171). Satisfactory voiding returned to 121 patients (70.8%). On backward stepwise multivariable analysis, PVP (odds ratio [OR] 0.27 [0.10-0.69]; p = 0.008), PAE (OR 5.27 [1.28-27.75]; p = 0.03), endoscopic enucleation (OR 0.08 [0-0.49]; p = 0.023), OP (OR 0.10 [0.01-0.57]; p = 0.034), Charlson score (OR 1.36 [1.14-1.66]; p = 0.001), and number of preoperative TWOC failure (OR 2.53 [1.23-5.51]; p = 0.014) were significantly associated with catheter-free survival. Conclusions: In this multi-institutional retrospective study, including patients with preoperative catheterization, the overall success rate of BPO surgery was 70.8% after 1-year follow-up. Compared with TURP, enucleation methods and PVP were associated with better catheter-free survival, whereas PAE was associated with higher risk of AUR recurrence.

Bipolar radiofrequency thermotherapy treatment of the prostate in urinary catheter-dependent men.

OBJECTIVES: In this study, for the first time in the literature, we evaluated patients with benign prostatic hyperplasia (BPH) who had undergone permanent urinary catheterization for urinary retention and who were treated with radiofrequency (RF) thermotherapy as an alternative method due to their inoperability based on the high risk associated with anesthesia. We aimed to investigate these patients' posttreatment parameters concerning the catheter-free rates, quality of life (QoL) changes, and retrospective treatment efficacy. METHODS: RF thermotherapy was applied to 62 permanent patients catheterized within the last 3 months due to urinary retention. The follow-up data of the patients were retrospectively analyzed. The patients who were free of catheters and those who required permanent catheterization were determined. The changes in the International Prostate Symptom Score (IPSS), QoL, postvoiding residue (PVR), and maximal flow rate (Qmax ) values were analyzed. RESULTS: A total of 52 patients were evaluated in terms of treatment success in relation to the elimination of the need for a urinary catheter, which was calculated as 73.07%. The Qmax , IPSS, QoL, and PVR values of 38 patients who no longer required a catheter were monitored for 24 months, and statistically significant changes were observed in all parameters. CONCLUSION: Bipolar RF thermotherapy was found to be beneficial for men dependent on catheters due to BPH. It can be recommended as a safe, minimally invasive treatment method for elderly patients with a high anesthesia risk.

Effect of preoperative gabapentin after transurethral prostate resection under general anesthesia. A randomized double-blind, placebo-controlled trial.

OBJECTIVES: To investigate whether preoperative oral gabapentin could reduce postoperative pain, analgesic consumption and the occurrence of catheter-related bladder discomfort (CRBD). Methods: In this study, participants randomly received either 600 mg gabapentin or placebo orally 2 h prior to transurethral prostate resection. Visual analogue scale and Ramsay sedation scale was utilized to assess pain intensity and sedation status after surgery. Intravenous 1.5 mg.kg-1 tramadol was used for postoperative analgesia. Pain intensity, sedation status, CRBD, tramadol consumption, side effects and the overall satisfaction degree were assessed and recorded for 48 h after tracheal extubation.  Results: Ninety participants given gabapentin and 91 participants given placebo completed the study. Lower visual analogue scale scores, less tramadol consumption, longer time to the first analgesic requirement, lower incidence of CRBD and nausea and higher satisfaction degree were detected in the patients receiving gabapentin compared with the patients receiving placebo.  Conclusion: Preoperative oral gabapentin reduced postoperative visual analogue scale scores, tramadol consumption and the occurrence rate of CRBD and nausea, and consequently, increased the degree of patients' satisfaction after transurethral prostate resection.

Multivariate Analysis of the Failure of Removal of the Urinary Catheter within 48 Hours after Transurethral Enucleation and Resection of the Prostate.

OBJECTIVE: To assess the value of clinically relevant data for predicting the failure of removal of the urinary catheter within 48 hours after TUERP. Materials and Methods. We retrospectively analyzed the medical records of 357 patients who underwent TUERP between January 2015 and July 2018, all of whom stopped bladder irrigation and removed urinary catheter within 48 hours after the operation. According to whether the removal of the catheter was successful, the patients were classified into 2 groups: Group A was successful and group B was a failure. Univariate analysis was performed to determine the association between the failure of removal of the catheter and the patients' preoperative clinical characteristics. Logistic regression analysis and receiver operating characteristic analysis (ROC) were conducted to establish the prediction model. Then the area under the curve (AUC) and the cut-off value were calculated. RESULTS: 357 patients were divided into group A (n = 305, 85.4%) and group B (n = 305, 85.4%) and group B (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (P=0.006), history of acute urinary retention (AUR) (. CONCLUSION: This study demonstrated that IPSS, QoL, drug medication, history of AUR, TPV, and IPP are independent factors associated with the failure of removal of the urethral catheter within 48 hours after TUERP.

Disperse red 15 (DR15) impedes biofilm formation of uropathogenic Escherichia coli.

Catheter associated urinary tract infection (CAUTI) is a highly prevalent hospital-acquired infection that is predominantly caused by uropathogenic Escherichia coli (UPEC). It adheres on catheter surface using type I pili as the initial step of pathogenesis that progresses to form biofilm. In this study, potential inhibitors against FimH adhesin of type I pili were screened computationally that yielded ten compounds. These were further validated in vitro against adhesion and biofilm formation. The compounds, 1-Amino-4-hydroxyanthraquinone (Disperse Red 15 or DR15) and 4-(4'-chloro-4-biphenylylsulfonylamino) benzoic acid (CB1) impaired adhesion and biofilm formation without inhibiting the planktonic growth. Also, both compounds inhibited cell assemblages like autoaggregation and swarming motility by unknown mechanisms. DR15 was further derivatised into N-(4-hydroxy-9,10-dioxo-9,10-dihydroanthracen-1-yl) undec-10-enamide that self-assembled with linseed oil, which was used as the coating material on urinary Foley catheters. The thin-film coating on the catheter did not leach when incubated in artificial urine and effectively restricted biofilm formation of UPEC. Altogether, the thin-film coating of urinary catheter with DR15 inhibited biofilm formation of UPEC and this application could potentially help to reduce CAUTI incidents in healthcare facilities.

Catheter management after benign transurethral prostate surgery: RAND/UCLA Appropriateness Criteria.

OBJECTIVES: To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use. STUDY DESIGN: RAND/UCLA Appropriateness Methodology. METHODS: Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7). RESULTS: Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate. CONCLUSIONS: We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

Risk factors and survival of patients infected with carbapenem-resistant Klebsiella pneumoniae in a KPC endemic setting: a case-control and cohort study.

BACKGROUND: Many gaps in the burden of resistant pathogens exist in endemic areas of low- and middle-income economies, especially those endemic for carbapenem resistance. The aim of this study is to evaluate risk factors for carbapenem-resistance, to estimate the association between carbapenem-resistance and all-cause 30-day mortality and to examine whether mortality is mediated by inappropriate therapy. METHODS: A case-control and a cohort study were conducted in one tertiary-care hospital in Medellín, Colombia from 2014 to 2015. Phenotypic and genotypic characterization of isolates was performed. In the case-control study, cases were defined as patients infected with carbapenem-resistant K. pneumoniae (CRKP) and controls as patients infected with carbapenem-susceptible K. pneumoniae (CSKP). A risk factor analysis was conducted using logistic regression models. In the cohort study, the exposed group was defined as patients infected with CRKP and the non-exposed group as patients infected with CSKP. A survival analysis using an accelerated failure time model with a lognormal distribution was performed to estimate the association between carbapenem resistance and all-cause 30-day-mortality and to examine whether mortality is mediated by inappropriate therapy. RESULTS: A total of 338 patients were enrolled; 49 were infected with CRKP and 289 with CSKP. Among CRKP isolates CG258 (n = 29), ST25 (n = 5) and ST307 (n = 4) were detected. Of importance, every day of meropenem (OR 1.18, 95%CI 1.10-1.28) and cefepime (OR 1.22, 95%CI 1.03-1.49) use increase the risk of carbapenem resistance. Additional risk factors were previous use of ciprofloxacin (OR 2.37, 95%CI 1.00-5.35) and urinary catheter (OR 2.60, 95%CI 1.25-5.37). Furthermore, a significant lower survival time was estimated for patients infected with CRKP compared to CSKP (Relative Times 0.44, 95%CI 0.24-0.82). The strength of association was reduced when appropriate therapy was included in the model (RT = 0.81 95%CI 0.48-1.37). CONCLUSION: Short antibiotic courses had the potential to reduce the selection and transmission of CRKP. A high burden in mortality occurred in patients infected with CRKP in a KPC endemic setting and CRKP leads to increased mortality via inappropriate antibiotic treatment. Furthermore, dissemination of recognized hypervirulent clones could add to the list of challenges for antibiotic resistance control.

Modifiable risk factors for multidrug-resistant Gram-negative infection in critically ill burn patients: a systematic review and meta-analysis.

BACKGROUND: We conducted a systematic review and meta-analysis to identify potentially modifiable risk factors for multidrug-resistant Gram-negative colonization or infection in critically ill burn patients. METHODS: A systematic search was conducted of PubMed, Embase, CINAHL, Web of Science and Central (Cochrane). Risk factors including antibiotic use and hospital interventions were summarized in a random-effects meta-analysis. Risk of publication bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation method and funnel plots. RESULTS: A total of 11 studies met the inclusion criteria. We identified several potentially modifiable risk factors and were able to grade their importance based on effect size. Related to prior antibiotic exposure, extended-spectrum cephalosporins (pooled odds ratio (OR) 7.00, 95% confidence interval (CI) 2.77-17.67), carbapenems (pooled OR 6.65, 95% CI 3.49-12.69), anti-pseudomonal penicillins (pooled OR 4.23, 95% CI 1.23-14.61) and aminoglycosides (pooled OR 4.20, 95% CI 2.10-8.39) were most significant. Related to hospital intervention, urinary catheters (pooled OR 11.76, 95% CI 5.03-27.51), arterial catheters (pooled OR 8.99, 95% CI 3.84-21.04), mechanical ventilation (pooled OR 5.49, 95% CI 2.59-11.63), central venous catheters (pooled OR 4.26, 95% CI 1.03-17.59), transfusion or blood product administration (pooled OR 4.19, 95% CI 1.48-11.89) and hydrotherapy (pooled OR 3.29, 95% CI 1.64-6.63) were most significant. CONCLUSION: Prior exposure to extended-spectrum cephalosporins and carbapenems, as well as the use of urinary catheters and arterial catheters pose the greatest threat for infection or colonization with multidrug-resistant Gram-negative organisms in the critically ill burn patient population.