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Background: Febrile neutropenia is a life-threatening condition commonly observed in patients with hematologic malignancies. The aim of this article is to provide updated knowledge about bloodstream infections in febrile neutropenia episodes within the Andean region of Latin America. Method: This retrospective study was based in 6 hospitals in Chile, Ecuador, and Peru and included adult patients with acute leukemia or lymphoma and febrile neutropenia between January 2019 and December 2020. Results: Of the 416 febrile neutropenia episodes, 38.7% had a bloodstream infection, 86% of which were caused by gram-negative rods, with Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa being the most frequently identified bacteria. K pneumoniae isolates were more frequently resistant than E coli to cefotaxime (65% vs 39.6%), piperacillin-tazobactam (56.7% vs 27.1%), and imipenem (35% vs 2.1%) and were more frequently multidrug resistant (61.7% vs 12.5%). Among P aeruginosa, 26.7% were resistant to ceftazidime, piperacillin-tazobactam, and imipenem, and 23.3% were multidrug resistant. Overall 30-day mortality was 19.8%, being higher with vs without a bloodstream infection (26.7% vs 15.3%, P = .005). Fever duration was also significantly longer, as well as periods of neutropenia and length of hospital stay for patients with bloodstream infection. Additionally, the 30-day mortality rate was higher for episodes with inappropriate vs appropriate empirical antibiotic therapy (41.2% vs 26.6%, P = .139). Conclusions: Considering the high rates of bacteria-resistant infection and 30-day mortality, it is imperative to establish strategies that reduce the frequency of bloodstream infections, increasing early identification of patients at higher risks of multidrug bacteria resistance, and updating existing empirical antibiotic recommendations.
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Resumen El objetivo de este estudio fue comparar los resultados de las pruebas de identificación y sensibilidad antimicrobiana obtenidos por los sistemas Vitek 2C (bioMérieux, Francia) y Phoenix (Becton Dickinson, EE.UU.) directamente a partir de hemocultivos positivos. Se realizó un estudio observacional prospectivo en el Hospital Naval Pedro Mallo de Buenos Aires, Argentina, que incluyó 70 bacteriemias monomicrobianas por gram negativos. Se obtuvo una identificación correcta por Vitek® 2C y por Phoenix del 100% y 97% respectivamente [p: no significativa (NS)]. La concordancia categórica para todos los antimicrobianos fue 97,1% y 98,1% (p: NS) con Vitek 2C y con Phoenix respectivamente. El tiempo medio para obtener un resultado fue de 10,19 h y 13,8 h (p: NS), respectivamente. Vitek 2C y Phoenix son herramientas importantes, rápidas y confiables para la identificación y las pruebas de sensibilidad realizadas directamente a partir de hemocultivos positivos.
Abstract The aim of this study was to compare the results of identification and antimicrobial susceptibility tests obtained by the Vitek 2C (bioMérieux, France) and Phoenix (Becton Dickinson, USA) systems directly from positive blood cultures. A prospective observational study was performed at the Pedro Mallo Navy Hospital in Buenos Aires, Argentina, which included 70 monomicrobial bacteremias by gram negative rods. Correct identification by Vitek® 2C and Phoenix was 100% and 97%, respectively [p: not significant (NS)]. Categorical agreement for all antimicrobials was 97.1% and 98.1% (p: NS) with Vitek 2C and Phoenix, respectively. The mean time to result was 10.19 h and 13.8 h (p: NS), respectively. Vitek 2C and Phoenix are important, rapid and reliable tools for identification and susceptibility testing when performed directly from positive blood cultures.
Resumo O objetivo deste estudo foi comparar os resultados dos testes de identificação e de suscetibilidade antimicrobiana obtidos pelos sistemas Vitek 2C (bioMérieux, França) e Phoenix (Becton Dickinson, EUA) diretamente a partir de culturas de sangue positivas. Foi realizado um estudo observacional prospectivo no Hospital Naval Pedro Mallo em Buenos Aires, Argentina, incluindo 70 bacteriemias monomicrobianas devido a gram negativos. A identificação correcta por Vitek® 2C e Phoenix obtida foi de 100% e 97% respectivamente [p: não significativo (NS)]. O acordo categórico para todos os antimicrobianos foi de 97,1% e 98,1% (p: NS) com Vitek 2C e Phoenix respectivamente. O tempo médio para obter o resultado foi de 10,19 h e 13,8 h (p: NS), respectivamente. Vitek 2C e Phoenix são ferramentas importantes, rápidas e fiáveis para a identificação e testes de sensibilidade realizados diretamente a partir de hemoculturas positivas.
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ABSTRACT Introduction: Multidrug-resistant gram-negative rods (MDR GNR) represent a growing threat for patients with cancer. Our objective was to determine the characteristics of and risk factors for MDR GNR bacteremia in patients with cancer and to develop a clinical score to predict MDR GNR bacteremia. Material and Methods: Multicenter prospective study analyzing initial episodes of MDR GNR bacteremia. Risk factors were evaluated using a multiple logistic regression (forward-stepwise selection) analysis including variables with a p < 0.10 in univariate analysis. Results: 394 episodes of GNR bacteremia were included, with 168 (42.6 %) being MDR GNR. Five variables were identified as independent risk factors: recent antibiotic use (OR = 2.8, 95 % CI 1.7-4.6, p = 0.001), recent intensive care unit admission (OR = 2.9, 95 % CI 1.1-7.8, p = 0.027), hospitalization ≥ 7 days prior to the episode of bacteremia (OR = 3.5, 95 % CI 2-6.2, p = 0.005), severe mucositis (OR = 5.3, 95 % CI 1.8-15.6, p = 0.002), and recent or previous colonization/infection with MDR GNR (OR = 2.3, 95 % CI 1.2-4.3, p = 0.028). Using a cut-off value of two points, the score had a sensitivity of 66.07 % (95 % CI 58.4-73.2 %), a specificity of 77.8 % (95 % CI 71.4-82.7 %), a positive predictive value of 68 % (95 % CI 61.9-73.4 %), and a negative predictive value of 75.9 % (95 % CI 71.6-79.7 %). The overall performance of the score was satisfactory (AUROC 0.78; 95 % CI 0.73-0.82). In the cases with one or none of the risk factors identified, the negative likelihood ratio was 0.18 and the post-test probability of having MDR GNR was 11.68 %. Conclusions: With the growing incidence of MDR GNR as etiologic agents of bacteremia in cancer patients, the development of this score could be a potential tool for clinicians.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Infecções por Bactérias Gram-Negativas/etiologia , Bacteriemia/etiologia , Medição de Risco/métodos , Farmacorresistência Bacteriana Múltipla , Bactérias Gram-Negativas/efeitos dos fármacos , Neoplasias/microbiologia , Argentina , Fatores de Tempo , Modelos Logísticos , Análise Multivariada , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Estatísticas não Paramétricas , Antibacterianos/uso terapêutico , Neoplasias/complicaçõesRESUMO
INTRODUCTION: Multidrug-resistant gram-negative rods (MDR GNR) represent a growing threat for patients with cancer. Our objective was to determine the characteristics of and risk factors for MDR GNR bacteremia in patients with cancer and to develop a clinical score to predict MDR GNR bacteremia. MATERIAL AND METHODS: Multicenter prospective study analyzing initial episodes of MDR GNR bacteremia. Risk factors were evaluated using a multiple logistic regression (forward-stepwise selection) analysis including variables with a p<0.10 in univariate analysis. RESULTS: 394 episodes of GNR bacteremia were included, with 168 (42.6 %) being MDR GNR. Five variables were identified as independent risk factors: recent antibiotic use (OR=2.8, 95 % CI 1.7-4.6, p=0.001), recent intensive care unit admission (OR=2.9, 95 % CI 1.1-7.8, p=0.027), hospitalization ≥ 7 days prior to the episode of bacteremia (OR=3.5, 95 % CI 2-6.2, p=0.005), severe mucositis (OR=5.3, 95 % CI 1.8-15.6, p=0.002), and recent or previous colonization/infection with MDR GNR (OR=2.3, 95 % CI 1.2-4.3, p=0.028). Using a cut-off value of two points, the score had a sensitivity of 66.07 % (95 % CI 58.4-73.2 %), a specificity of 77.8 % (95 % CI 71.4-82.7 %), a positive predictive value of 68 % (95 % CI 61.9-73.4 %), and a negative predictive value of 75.9 % (95 % CI 71.6-79.7 %). The overall performance of the score was satisfactory (AUROC 0.78; 95 % CI 0.73-0.82). In the cases with one or none of the risk factors identified, the negative likelihood ratio was 0.18 and the post-test probability of having MDR GNR was 11.68 %. CONCLUSIONS: With the growing incidence of MDR GNR as etiologic agents of bacteremia in cancer patients, the development of this score could be a potential tool for clinicians.
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Bacteriemia/etiologia , Farmacorresistência Bacteriana Múltipla , Bactérias Gram-Negativas/efeitos dos fármacos , Infecções por Bactérias Gram-Negativas/etiologia , Neoplasias/microbiologia , Medição de Risco/métodos , Adulto , Antibacterianos/uso terapêutico , Argentina , Feminino , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Neoplasias/complicações , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Estatísticas não Paramétricas , Fatores de Tempo , Adulto JovemRESUMO
Os resíduos de serviços de saúde suscitam polêmica quanto a importância para a saúde humana, animal e ambiental. Avaliou-se a ocorrência de bactérias clinicamente relevantes na pilha de resíduos de serviços de saúde em um aterro sanitário e seu perfil de susceptibilidade aos antimicrobianos. Alíquotas de chorume foram processadas para isolamento seletivo de Staphylococcus sp, bastonetes Gram negativos da família Enterobacteriaceae e não fermentadores. Resistência bacteriana a todos os antimicrobianos testados foi observada em todos os grupos microbianos, além de resistência a mais de uma droga. Os resultados permitem sugerir que bactérias viáveis nos resíduos de serviços de saúde representam riscos à saúde humana e animal. Além disso, a ocorrência de linhagens multirresistentes sustenta a hipótese dos resíduos de serviços de saúde atuarem como reservatórios de marcadores de resistência, com impacto ambiental. A falta de legislação regional de segregação, tratamento e destino de resíduos podem expor diferentes populações a riscos de transmissão de doenças infecciosas associadas a microrganismos multirresistentes.
Health service waste gives rise to controversy regarding its importance for human, animal and environmental health. Occurrences of clinically relevant bacteria in piles of health service waste in a sanitary landfill and their antimicrobial susceptibility profile were evaluated. Aliquots of leachate were processed for selective isolation of Staphylococcus sp, Gram-negative rods of the Enterobacteriaceae family and non-fermenters. Bacterial resistance to all the antimicrobials tested was observed in all microbial groups, including resistance to more than one drug. The results make it possible to suggest that viable bacteria in health service waste represent risks to human and animal health. Furthermore, occurrences of multiresistant strains support the hypothesis that health service waste acts as a reservoir for resistance markers, with an environmental impact. The lack of regional legislation concerning segregation, treatment and final disposal of waste may expose different populations to risks of transmission of infectious diseases associated with multiresistant microorganisms
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Humanos , Antibacterianos/farmacologia , Farmacorresistência Bacteriana , Enterobacteriaceae/efeitos dos fármacos , Resíduos de Serviços de Saúde , Staphylococcus/efeitos dos fármacos , Brasil , Farmacorresistência Bacteriana Múltipla , Enterobacteriaceae/classificação , Enterobacteriaceae/isolamento & purificação , Eliminação de Resíduos de Serviços de Saúde , Testes de Sensibilidade Microbiana , Staphylococcus/classificação , Staphylococcus/isolamento & purificaçãoRESUMO
Las infeccionesproducidas por microorganismos multirresistentes son uno de los mayores problemas en los centros asistenciales. Frecuentemente, sólo las polimixinas muestran actividad “in vitro” frente a aislamientos de bacilos gram-negativos resistentes a los carbapenemes. Sin embargo, el National Committee for Clinical Laboratory Standards (NCCLS) no incluye, actualmente, recomendaciones para la realización de las pruebas de sensibilidad para este grupo de antibióticos. Se determinóla actividad de colistín y la correlación entre las pruebas de difusión y dilución de este antibiótico frente a 186 aislamientos contemporáneos en el Hospital de Clínicas “José de San Martín”, siguiendo las recomendaciones generales del NCCLS. Se evaluaron dos puntos de corte: NCCLS 1981 (resistente £ 8 mm y sensible > 11mm) y R. Jones 2001 (resistente £ 11mm y sensible > 14mm). Utilizando el punto de corte del NCCLS 1981 se cometieron los siguientes errores: 0,5% “minor”; 2,2% “major” y 4,4% “very major”, mientras que con el propuesto por R. Jones 2001: 18,9% “minor”; 3,8% “major” y 0,5% “very major”. En conclusión, dado que el punto de corte utilizado por R. Jones 2001 disminuye el error “very major” pero aumenta el “minor” se recomienda la utilización de la concentración inhibitoria mínima (CIM) para confirmar la sensibilidad a colistín cuando sea usada en el tratamiento de infecciones, sin embargo no se detectó resistencia a colistín con halos de inhibición > a 16 mm.
Infections produced by multidrug resistant organisms are one of the greatest problems in health centers. Often, only polymyxines show good activity “in vitro” against the carbapenem resistant gram-negative strains; but the National Committee for Clinical Laboratory Standards (NCCLS) documents do not currently provide interpretative criteria for testing the polymyxines.The antimicrobial activity ofcolistin,and the correlation betweenthe agar dilution test and disk diffusion test were evaluated against 186 gram-negative strains isolated at the Hospital de Clínicas “José de San Martín” of Buenos Aires city. All susceptibility tests were performed according to the NCCLS recommendations. Were evaluated two breakpoints, NCCLS 1981 (£ 8mm and >11mm), and R. Jones 2001 (£ 11 mm and > 14 mm). Discrepancies on interpretative category were found (0.5% minor; 2.2% major and 4.4% very major) with NCCLS 1981, and (18.9% minor; 3.8% majorand 0.5% very major) with R. Jones 2001 criteria. Conclusions. In spite of the fact that the breakpoint used by R. Jones 2001decreases the very major error but increases the minor error, according to our results we recommend the use of MIC methods to assist the therapeutic application of colistin; however resistance to colistin was not detected with zone diameters > 16mm.