Colonization with broad-spectrum cephalosporin-resistant Gram-negative bacilli in intensive care units during a nonoutbreak period

D’Agata, Erika M. C.; Venkataraman, Lata; DeGirolami, Paola C.; Burke, Patricia A.; Eliopoulos, George M.; Karchmer, Adolf W.; Samore, Matthew H.

doi:10.1097/00003246-199906000-00026

Cited by 71 publications

(38 citation statements)

References 28 publications

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“…The univariate analysis of risk factors strongly correlates the cases of ESBL-PS carriage with the evidence for infection with this class of bacteria, immunosuppressive factors, and both general and abnormal surgery. This agrees with many previous studies that highlighted the importance of colonization pressure on the risk of acquisition of resistant bacteria (D'Agata et al, 1999;Merrer et al, 2000;Nseir et al, 2005;Toltzis et al, 1997). A thorough analysis of the changes occurring in ESBL-PS carriage during ICU stay (Fig.…”

Section: Discussionsupporting

confidence: 91%

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Extended spectrum β-lactamase producing Enterobacteriaceae in Lebanese ICU patients: Epidemiology and patterns of resistance

Daoud

Moubareck²,

Hakime

et al. 2006

J. Gen. Appl. Microbiol.

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Our study aims to investigate and describe the epidemiology of the intestinal carriage of ESBL-PS in intensive care units of five Lebanese hospitals and to analyze the potential risk factors for the acquisition of these strains. At the same time, we intend to determine the patterns of susceptibility of these strains, exploring therefore the availability of alternative treatment. One thousand, four hundred forty-two fecal samples were collected between January 1, 2003 and March 31, 2003 from 378 patients admitted to the ICUs of five Lebanese tertiary care general hospitals located in different areas of Lebanon. ESBL production was detected by the double disk synergy test and antibiotic susceptibility of ESBL-producing strains as well as minimum inhibitory concentrations were determined. A paired case-control study was undertaken to identify risk factors for carriage of ESBL-PS. One hundred eighteen strains isolated from 72 subjects were identified as ESBL producers, including 95 (80.5%) E. coli, 16 (13.6%) Klebsiella pneumoniae, and 7 (5.6%) Enterobacter cloacae. A higher rate of multiple ESBL-PS carriage was described among these acquisition cases (21 double carriages and 3 triple carriages of ESBL-PS compared to only 1 double carriage of ESBL-PS at admission). In general, similar trends of susceptibility were observed in the different hospitals. As expected, the lowest MIC was observed with imipenem for all E. coli, Klebsiella, and Enterobacter isolates. Ciprofloxacin, followed by trimethoprim-sulfamethoxazole seem to be associated with the lowest susceptibility. In vitro susceptibility to cefoxitin for all isolates was 74.6%; more resistance was associated to ceftazidime (90.7%) than to cefotaxime (69.7%). Our data agree with other national and international reports showing the increase in ESBL-PS carriage in ICU patients. They demonstrate the endemic character of this carriage in Lebanese hospitals and the important risk factors including immunosuppression and evidence of ESBL infection. The highly resistant profile of ESBL-PS to antimicrobial agents available for treatment reflects the severity of this issue. The significance of this study resides in the direct correlation between our results and the nationwide increase in multi-drug resistant bacteria and the continuous change in bacterial resistance epidemiology. Our data may have an important impact on infection control policies in hospitals and on treatment of infectious diseases.

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Section: Discussionsupporting

confidence: 91%

“…In cases where ESBL-PS has become prevalent, the adequacy of 3rd generation cephalosporins as empirical antibiotics for serious gram negative infections in critically ill patients has been put in doubt. Carbapenems and piperacilline/ tazobactam became the systematic alternative agents (Babini and Livemore, 2000;D'Agata et al, 1999).…”

Section: Discussionmentioning

confidence: 99%

Extended spectrum β-lactamase producing Enterobacteriaceae in Lebanese ICU patients: Epidemiology and patterns of resistance

Daoud

Moubareck²,

Hakime

et al. 2006

J. Gen. Appl. Microbiol.

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“…Interestingly, exposures to narrow-and expanded-spectrum cephalosporins were not associated with the emergence of resistance, nor was exposure to ureidopenicillins or to ␤-lactam-␤-lactamase inhibitor combination agents. This finding is in accord with some studies (2, 6), but not with others (4,5). Quinolone therapy was associated with decreased risk for emergence of broad-spectrum cephalosporin-resistant Enterobacter spp.…”

supporting

confidence: 90%

Risk Factors for Emergence of Resistance to Broad-Spectrum Cephalosporins among Enterobacter spp

Kaye

Cosgrove

Harris

et al. 2001

Antimicrob Agents Chemother

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156

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Among 477 patients with susceptible Enterobacter spp., 49 subsequently harbored third-generation cephalosporin-resistant Enterobacter spp. Broad-spectrum cephalosporins were independent risk factors for resistance (relative risk [OR] ‫؍‬ 2.3, P ‫؍‬ 0.01); quinolone therapy was protective (OR ‫؍‬ 0.4, P ‫؍‬ 0.03). There were trends toward decreased risk for resistance among patients receiving broad-spectrum cephalosporins and either aminoglycosides or imipenem. Of the patients receiving broad-spectrum cephalosporins, 19% developed resistance.Enterobacter spp. are among the most common gram-negative pathogens associated with hospital infections, representing 6% of all nosocomial isolates recovered and 11% of pneumonia isolates (8).Resistance to ␤-lactam antibiotics often complicates the treatment of Enterobacter infections (2, 6). In a recent report, 36% of Enterobacter spp. infections in intensive care units were resistant to broad-spectrum cephalosporins (9). Most commonly, resistance to third-generation cephalosporins in this organism is mediated by chromosomal AmpC cephalosporinase. Although isolates often appear susceptible in vitro, antibiotic pressure can facilitate the emergence of derepressed mutant Enterobacter cells which produce AmpC ␤-lactamases at high levels constitutively (12; A. A. Medeiros, Editorial, Clin. Infect. Dis. 25:341-342, 1996). In addition, exposure to certain ␤-lactam antibiotics results in increased synthesis of AmpC and induction of resistance to broad-spectrum cephalosporins.A landmark study by Chow et al. showed a strong correlation between previous broad-spectrum cephalosporin exposure and the isolation of Enterobacter spp. resistant to these agents (2). Although the study demonstrated emergence of resistance during therapy of Enterobacter bacteremia with broad-spectrum cephalosporins in 19% of patients, the prospective nature of this study precluded a large enough sample size on which conclusive analysis of risk factors for emergence of resistance could be performed (only six patients showed the emergence of a resistant strain). No study to date has had enough statistical power to study this question comprehensively. We applied here effective analytical methods to a large study cohort to measure the effects of antimicrobial agent exposures on the emergence of broad-spectrum cephalosporin resistance among Enterobacter spp. We analyzed antimicrobial risk factors as timedependent variables (7) so that risk estimates would account for the duration of time an individual was exposed to an antimicrobial agent only after therapy with the agent had commenced, thus decreasing the potential for bias.The study design was a retrospective cohort. All patients admitted to Beth Israel Deaconess Medical Center, West Campus, Boston, Mass., between October 1993 and September 1997 with cultures positive for Enterobacter spp. susceptible to broadspectrum cephalosporins were included in the study. Patients remained in the cohort until Enterobacter spp. resistant to broadspectrum cephalosporins were i...

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“…If resistance is rare, the probability of misclassification is low, and clinical samples may practically be used for studying antibiotic resistance. However, if resistance is common, it is preferable to use the outcome of colonization, which generally precedes infection and affects more patients (35,36).…”

Section: Measuring Outcome: Antibiotic Resistancementioning

confidence: 99%

Epidemiological Interpretation of Studies Examining the Effect of Antibiotic Usage on Resistance

et al. 2013

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SUMMARY Bacterial resistance to antibiotics is a growing clinical problem and public health threat. Antibiotic use is a known risk factor for the emergence of antibiotic resistance, but demonstrating the causal link between antibiotic use and resistance is challenging. This review describes different study designs for assessing the association between antibiotic use and resistance and discusses strengths and limitations of each. Approaches to measuring antibiotic use and antibiotic resistance are presented. Important methodological issues such as confounding, establishing temporality, and control group selection are examined.

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Colonization with broad-spectrum cephalosporin-resistant Gram-negative bacilli in intensive care units during a nonoutbreak period

Cited by 71 publications

References 28 publications

Extended spectrum β-lactamase producing Enterobacteriaceae in Lebanese ICU patients: Epidemiology and patterns of resistance

Extended spectrum β-lactamase producing Enterobacteriaceae in Lebanese ICU patients: Epidemiology and patterns of resistance

Risk Factors for Emergence of Resistance to Broad-Spectrum Cephalosporins among Enterobacter spp

Epidemiological Interpretation of Studies Examining the Effect of Antibiotic Usage on Resistance

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