RESUMO
We describe 9 patients at a medical center in Detroit, Michigan, USA, with severe acute respiratory syndrome coronavirus 2 and Clostridioides difficile. Both infections can manifest as digestive symptoms and merit screening when assessing patients with diarrhea during the coronavirus disease pandemic. These co-infections also highlight the continued importance of antimicrobial stewardship.
Assuntos
Betacoronavirus , Clostridioides difficile , Infecções por Clostridium/epidemiologia , Coinfecção/epidemiologia , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Adulto , Idoso , Antibacterianos/efeitos adversos , Gestão de Antimicrobianos , COVID-19 , Infecções por Clostridium/induzido quimicamente , Infecções por Clostridium/microbiologia , Coinfecção/microbiologia , Infecções por Coronavirus/microbiologia , Feminino , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/microbiologia , Vigilância da População , SARS-CoV-2RESUMO
A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum ß-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially bla(CTX-M-15) type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.
Assuntos
Infecções por Escherichia coli/epidemiologia , Proteínas de Escherichia coli/metabolismo , Escherichia coli/isolamento & purificação , beta-Lactamases/metabolismo , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Estudos de Casos e Controles , Ciprofloxacina/farmacologia , Infecções Comunitárias Adquiridas/microbiologia , Farmacorresistência Bacteriana Múltipla , Escherichia coli/efeitos dos fármacos , Escherichia coli/enzimologia , Escherichia coli/genética , Infecções por Escherichia coli/tratamento farmacológico , Proteínas de Escherichia coli/genética , Feminino , Genes Bacterianos , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Combinação Trimetoprima e Sulfametoxazol/farmacologia , Estados Unidos/epidemiologia , Cateteres Urinários/microbiologia , Infecções Urinárias/microbiologia , beta-Lactamases/genéticaRESUMO
Ertapenem is active against extended-spectrum-ß-lactamase (ESBL)-producing Enterobacteriaceae organisms but inactive against Pseudomonas aeruginosa and Acinetobacter baumannii. Due to a lack of therapeutic data for ertapenem in the treatment of ESBL bloodstream infections (BSIs), group 2 carbapenems (e.g., imipenem or meropenem) are often preferred for treatment of ESBL-producing Enterobacteriaceae, although their antipseudomonal activity is unnecessary. From 2005 to 2010, 261 patients with ESBL BSIs were analyzed. Outcomes were equivalent between patients treated with ertapenem and those treated with group 2 carbapenems (mortality rates of 6% and 18%, respectively; P = 0.18).
Assuntos
Antibacterianos/uso terapêutico , Infecções por Enterobacteriaceae/tratamento farmacológico , Enterobacteriaceae/efeitos dos fármacos , beta-Lactamases/metabolismo , beta-Lactamas/uso terapêutico , Idoso , Estudos de Coortes , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/microbiologia , Farmacorresistência Bacteriana , Enterobacteriaceae/enzimologia , Infecções por Enterobacteriaceae/microbiologia , Ertapenem , Infecções por Escherichia coli/tratamento farmacológico , Infecções por Escherichia coli/microbiologia , Feminino , Humanos , Infecções por Klebsiella/tratamento farmacológico , Infecções por Klebsiella/microbiologia , Klebsiella pneumoniae , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Guidelines recommend that agents other than vancomycin be considered for some types of infection due to methicillin-resistant Staphylococcus aureus (MRSA) when the minimum inhibitory concentration (MIC) to vancomycin is 2 µg/mL or more. Alternative therapeutic options include daptomycin and linezolid, 2 relatively new and expensive drugs, and trimethoprim/sulfamethoxazole (TMP/SMX), an old and inexpensive agent. OBJECTIVE: To compare the clinical efficacy and potential cost savings associated with use of TMP/SMX compared to linezolid and daptomycin. METHODS: A retrospective study was conducted at Detroit Medical Center. For calendar year 2009, unique adults (age >18 years) with infections due to MRSA with an MIC to vancomycin of 2 µg/mL were included if they received 2 or more doses of TMP/SMX and/or daptomycin and/or linezolid. Data were abstracted from patient charts and pharmacy records. RESULTS: There were 328 patients included in the study cohort: 143 received TMP/SMX alone, 89 received daptomycin alone, 75 received linezolid alone, and 21 patients received a combination of 2 or more of these agents. In univariate analysis, patients who received TMP/SMX alone had significantly better outcomes, including in-hospital (p = 0.003) and 90-day mortality (p < 0.001) compared to patients treated with daptomycin or linezolid. Patients receiving TMP/SMX were also younger (p < 0.001), had fewer comorbid conditions (p < 0.001), had less severe acute severity of illness (p < 0.001), and received appropriate therapy more rapidly (p = 0.001). In multivariate models the association between TMP/SMX treatment and mortality was no longer significant. Antimicrobial cost savings associated with using TMP/SMX averaged $2067.40 per patient. CONCLUSIONS: TMP/SMX monotherapy compared favorably to linezolid and daptomycin in terms of treatment efficacy and mortality. Use of TMP/SMX instead of linezolid or daptomycin could potentially significantly reduce antibiotic costs. TMP/SMX should be considered for the treatment of MRSA infection with MIC of 2 µg/mL to vancomycin.
Assuntos
Antibacterianos/uso terapêutico , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Infecções Estafilocócicas/tratamento farmacológico , Acetamidas/administração & dosagem , Acetamidas/economia , Acetamidas/uso terapêutico , Adulto , Fatores Etários , Idoso , Antibacterianos/administração & dosagem , Antibacterianos/economia , Estudos de Coortes , Redução de Custos , Daptomicina/administração & dosagem , Daptomicina/economia , Daptomicina/uso terapêutico , Custos de Medicamentos , Feminino , Humanos , Linezolida , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Análise Multivariada , Oxazolidinonas/administração & dosagem , Oxazolidinonas/economia , Oxazolidinonas/uso terapêutico , Estudos Retrospectivos , Índice de Gravidade de Doença , Infecções Estafilocócicas/economia , Infecções Estafilocócicas/microbiologia , Fatores de Tempo , Resultado do Tratamento , Combinação Trimetoprima e Sulfametoxazol/administração & dosagem , Combinação Trimetoprima e Sulfametoxazol/economia , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Vancomicina/administração & dosagem , Vancomicina/farmacologiaRESUMO
Carbapenem-resistant Klebsiella pneumoniae has spread worldwide and throughout the United States. Colistin is used extensively to treat infections with this organism. We describe a cluster of colistin-resistant, carbapenem-resistant K. pneumoniae infection cases involving three institutions in Detroit, MI. A cluster of five cases of colistin-resistant, carbapenem-resistant K. pneumoniae was identified at Detroit Medical Center (DMC) from 27 July to 22 August 2009. Epidemiologic data were collected, and transmission opportunities were analyzed. Isolates were genotyped by using pulsed-field gel electrophoresis and repetitive extragenic palindromic PCR. Data regarding the use of colistin were obtained from pharmacy records. The index case of colistin-resistant, carbapenem-resistant K. pneumoniae was followed 20 days later by four additional cases occurring in a 6-day interval. All of the patients, at some point, had stayed at one particular institution. The mean number of opportunities for transmission between patients was 2.3 ± 0.5, and each patient had at least one opportunity for transmission with one of the other patients. Compared to 60 colistin-susceptible, carbapenem-resistant K. pneumoniae controls isolated in the previous year at DMC, case patients were significantly older (P = 0.05) and the carbapenem-resistant K. pneumoniae organisms isolated from them displayed much higher MICs to imipenem (P < 0.001). Colistin use was not enhanced in the months preceding the outbreak. Genotyping revealed two closely related clones. This report of a colistin-resistant, carbapenem-resistant K. pneumoniae outbreak is strongly linked to patient-to-patient transmission. Controlling the spread and novel emergence of bacteria with this phenotype is of paramount importance.
Assuntos
Antibacterianos/farmacologia , Carbapenêmicos/farmacologia , Colistina/farmacologia , Surtos de Doenças , Hospitais Universitários , Infecções por Klebsiella/epidemiologia , Klebsiella pneumoniae/efeitos dos fármacos , Idoso , Idoso de 80 Anos ou mais , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Farmacorresistência Bacteriana Múltipla , Feminino , Genótipo , Humanos , Infecções por Klebsiella/microbiologia , Infecções por Klebsiella/transmissão , Klebsiella pneumoniae/genética , Klebsiella pneumoniae/isolamento & purificação , Masculino , Michigan/epidemiologia , Testes de Sensibilidade Microbiana , Reação em Cadeia da PolimeraseRESUMO
We conducted a comparative retrospective study to quantify the impact of coronavirus disease 2019 (COVID-19) on patient safety. We found a statistically significant increase in central-line-associated bloodstream infections and blood culture contamination rates during the pandemic. Increased length of stay and mortality were also observed during the COVID-19 pandemic.
Assuntos
COVID-19 , Sepse , Hemocultura , Humanos , Pandemias , Estudos Retrospectivos , SARS-CoV-2RESUMO
BACKGROUND: Basins used for patient bathing have been shown to be contaminated with multidrug-resistant organisms (MDROs) and have prompted the evaluation of alternatives to soap and water bathing methods. METHODS: We conducted a prospective, randomized, open-label interventional crossover study to assess the impact of replacing traditional bath basins with prepackaged washcloths on the incidence of hospital-associated infections (HAIs), MDROs, and secondarily, rates of skin deterioration. Unit-wide use of disposable washcloths over an 8-month period was compared with an 8-month period of standard care using basins. RESULTS: A total of 2,637 patients were included from 2 medical-surgical units at a single tertiary medical center, contributing 16,034 patient days. During the study period, there were a total of 33 unit-acquired infections, the rates of which were not statistically different between study phases (incidence rate ratio, 1.05; 95% confidence interval [CI], 0.50-2.23; P = .88). However, occurrence of skin integrity deterioration was significantly less in the intervention group (odds ratio, 0.44; 95% CI, 0.22-0.88; P = .02). CONCLUSIONS: Although we were unable to demonstrate a significant reduction in HAI or MDRO acquisition, we found a decrease in skin deterioration with the use of disposable washcloths and confirmed earlier findings of MDRO contamination of wash basins.
Assuntos
Banhos/métodos , Roupas de Cama, Mesa e Banho , Infecção Hospitalar/prevenção & controle , Infecções Cutâneas Estafilocócicas/prevenção & controle , Adulto , Anti-Infecciosos Locais/farmacologia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/transmissão , Estudos Cross-Over , Desinfetantes/farmacologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Staphylococcus aureus Resistente à Meticilina/patogenicidade , Staphylococcus aureus Resistente à Meticilina/fisiologia , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções Cutâneas Estafilocócicas/tratamento farmacológico , Infecções Cutâneas Estafilocócicas/microbiologia , Infecções Cutâneas Estafilocócicas/transmissãoRESUMO
OBJECTIVE: To assess the impact of active alerting of positive blood culture data coupled with stewardship intervention on time to appropriate therapy, length of stay, and mortality in patients with gram-negative bacteremia. DESIGN: Quasi-experimental retrospective cohort study in patients with gram-negative bacteremia at the Detroit Medical Center from 2009 to 2011. SETTING: Three hospitals (1 community, 2 academic) with active antimicrobial stewardship programs within the Detroit Medical Center. PATIENTS: All patients with monomicrobial gram-negative bacteremia during the study period. INTERVENTION: Active alerting of positive blood culture data coupled with stewardship intervention (2010-2011) compared with patients who received no formalized stewardship intervention (2009). RESULTS: Active alerting and intervention led to a decreased time to appropriate therapy (8 [interquartile range (IQR), 2-24] vs 14 [IQR, 2-35] hours; P = .014) in patients with gram-negative bacteremia. After controlling for differences between groups, being in the intervention arm was associated with an independent reduction in length of stay (odds ratio [OR], 0.73 [95% confidence interval (CI), 0.62-0.86]), correlating to a median attributable decrease in length of stay of 2.2 days. Additionally, multivariate modeling of patients who were not on appropriate antimicrobial therapy at the time of initial culture positivity showed that patients in the intervention group had a significant reduction in both length of stay (OR, 0.76 [95% CI, 0.66-0.86]) and infection-related mortality (OR, 0.24 [95% CI, 0.08-0.76]). CONCLUSIONS: Active alerting coupled with stewardship intervention in patients with gram-negative bacteremia positively impacted time to appropriate therapy, length of stay, and mortality and should be a target of antimicrobial stewardship programs.
Assuntos
Antibacterianos , Bacteriemia/tratamento farmacológico , Infecção Hospitalar/tratamento farmacológico , Revisão de Uso de Medicamentos , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Tempo de Internação , Sistemas de Alerta , Centros Médicos Acadêmicos/estatística & dados numéricos , Antibacterianos/uso terapêutico , Bacteriemia/microbiologia , Infecção Hospitalar/microbiologia , Feminino , Bactérias Gram-Negativas/efeitos dos fármacos , Infecções por Bactérias Gram-Negativas/microbiologia , Hospitais Comunitários/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Gender reassignment surgery (i.e., male-to-female or female-to-male) entails a series of complex surgical procedures. We conducted a study to explore epidemiologic characteristics of patients who underwent genital reconstruction operations as components of gender reassignment and to analyze risk factors for surgical-site infections (SSIs) following these operations. METHODS: The study was a retrospective cohort study conducted from 1984-2008 at Harper University Hospital, a tertiary hospital with 625 beds in Detroit, Michigan. Surgical site infection was defined according to established criteria. RESULTS: Records were available for 82 patients who underwent a total of 1,383 operations as part of genital-reconstruction processes. Thirty-nine (47.6%) of the patients underwent female-to-male reassignment (FTM) and 43 (52.4%) underwent male-to-female reassignment (MTF). The average age of the study cohort was 39.5±9.8 y. Of the patients in the cohort, 56 (68.3%) were Caucasian and 67 (81.7%) were single. The average number of operative encounters per patient was 11.8±4.6 for FTM and 4.9±2.4 for MTF. Forty-three (52.4%) patients developed an SSI at least once during their genital reconstruction process, of whom 34 (87%) were in the FTM group and nine (21%) in the MTF group (p<0.001). Staphylococci were the most common pathogens (61%) isolated in these infections, followed by Enterobacteriaceae (50%), Enterococcus (39%), and Pseudomonas aeruginosa (33.3%). Surgical site infection was associated independently with an increased frequency of operative procedures and operating room encounters. CONCLUSIONS: More than 50% of patients who underwent genital reconstruction operations developed an SSI at some point during the genital reconstruction process. Surgical site infections are more common in FTM than in MTF reconstruction operations, and for both FTM and MTF, SSIs are associated independently with an increased frequency of total operative procedures and encounters.
Assuntos
Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Cirurgia de Readequação Sexual/efeitos adversos , Cirurgia de Readequação Sexual/estatística & dados numéricos , Infecção da Ferida Cirúrgica/epidemiologia , Adulto , Bactérias/isolamento & purificação , Feminino , Fungos/isolamento & purificação , Genitália/cirurgia , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Análise Multivariada , Fatores de Risco , Infecção da Ferida Cirúrgica/microbiologiaRESUMO
The hospital environment is increasingly recognized as a reservoir for hospital-acquired pathogens. During a 44-month study period, a total of 1,103 basins from 88 hospitals in the United States and Canada were sampled. Overall, 62.2% of the basins (at least 1 basin at each hospital) were contaminated with commonly encountered hospital-acquired pathogens.
Assuntos
Bactérias/efeitos dos fármacos , Bactérias/isolamento & purificação , Banhos , Farmacorresistência Bacteriana Múltipla , Microbiologia Ambiental , Canadá , Hospitais , Humanos , Estados UnidosRESUMO
BACKGROUND: Therapeutic options are limited for infections because of Acinetobacter baumannii and carbapenem-resistant Enterobacteriaceae (CRE). Study aim was to compare the efficacy of colistin to tigecycline for the treatment of these types of infections. METHODS: A retrospective study was conducted at the Detroit Medical Center. Adult patients with infections because of A baumannii or CRE in 2009 who received ≥2 doses of colistin or tigecycline were studied. Risk factors, outcomes, and costs were analyzed. RESULTS: There were 82 patients with infections because of A baumannii, 12 with CRE, and 12 with A baumannii and CRE coinfection. Seventy-one patients received colistin, 16 received tigecycline, and 19 received both colistin and tigecycline. Seven isolates were nonsusceptible to colistin and 79 to tigecycline. Patients receiving colistin alone or in combination were more likely to die during their hospitalization than patients receiving only tigecycline (P = .002). However, patients receiving colistin had higher severity of acute illness and had notable delays in initiation of effective antimicrobial therapy (P < .001). CONCLUSION: Compared with patients who received tigecycline alone, patients who received colistin alone or in combination had a higher severity of acute illness indices and delays in initiation of effective therapy. This increased severity of illness contributed to the increased rate of mortality among patients treated with colistin for A baumannii or CRE infections.
Assuntos
Infecções por Acinetobacter/tratamento farmacológico , Antibacterianos/uso terapêutico , Colistina/uso terapêutico , Infecções por Enterobacteriaceae/tratamento farmacológico , Minociclina/análogos & derivados , Resistência beta-Lactâmica , Acinetobacter baumannii/efeitos dos fármacos , Adulto , Idoso , Antibacterianos/farmacologia , Carbapenêmicos/farmacologia , Estudos de Casos e Controles , Estudos de Coortes , Enterobacteriaceae/efeitos dos fármacos , Infecções por Enterobacteriaceae/microbiologia , Feminino , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Minociclina/uso terapêutico , Estudos Retrospectivos , Índice de Gravidade de Doença , Análise de Sobrevida , Tigeciclina , Resultado do TratamentoRESUMO
Linezolid is an important agent for the treatment of infections because of vancomycin-resistant Enterococcus (VRE). This study identified independent predictors for isolation of linezolid-resistant VRE (LZD-R-VRE) and analyzed outcomes associated with linezolid resistance. Immunosuppression, prior surgery, and previous exposure to ß-lactam antibiotics were independent predictors for isolation of LZD-R-VRE but not for LZD-susceptible-VRE. Prior exposure to linezolid was not a predictor for isolation of LZD-R-VRE.
Assuntos
Acetamidas/uso terapêutico , Farmacorresistência Bacteriana , Enterococcus/efeitos dos fármacos , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/epidemiologia , Oxazolidinonas/uso terapêutico , Vancomicina/farmacologia , Acetamidas/farmacologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Enterococcus/isolamento & purificação , Feminino , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Linezolida , Masculino , Pessoa de Meia-Idade , Oxazolidinonas/farmacologia , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between "present on admission" (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO). METHODS: A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded. RESULTS: Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001). CONCLUSION: Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure.