Intestinal decontamination of multidrug-resistant Klebsiella pneumoniae after recurrent infections in an immunocompromised host

Kronman, Matthew P.; Zerr, Danielle M.; Qin, Xuan; Englund, Janet A.; Cornell, Cathy; Sanders, Jean E.; Myers, Jeffrey; Rayar, Jaipreet; Berry, Jessica E.; Adler, Amanda; Weissman, Scott J.

doi:10.1016/j.diagmicrobio.2014.06.006

Cited by 13 publications

(9 citation statements)

References 15 publications

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“…However, it will be critical to examine decolonization therapy on a larger scale with particular attention to adverse outcomes, especially the emergence of further resistance in the targeted organisms. Fecal microbial transplantation might evolve as an alternative, less toxic strategy to restore a healthy intestinal microbiome to eliminate CRE colonization [33]. …”

Section: Discussionmentioning

confidence: 99%

Carbapenem-resistant Enterobacteriaceae colonization (CRE) and subsequent risk of infection and 90-day mortality in critically ill patients, an observational study

et al. 2017

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BackgroundCarbapenem-resistant Enterobacteriaceae (CRE) have emerged as an urgent public health threat. Intestinal colonization with CRE has been identified as a risk factor for the development of systemic CRE infection, but has not been compared to colonization with third and/or fourth generation cephalosporin-resistant (Ceph-R) Enterobacteriaceae. Moreover, the risk conferred by colonization on adverse outcomes is less clear, particularly in critically ill patients admitted to the intensive care unit (ICU).MethodsWe carried out a cohort study of consecutive adult patients screened for rectal colonization with CRE or Ceph-R upon ICU entry between April and July 2013. We identified clinical variables and assessed the relationship between CRE or Ceph-R colonization and subsequent systemic CRE infection within 30 days (primary outcome) and all-cause mortality within 90 days (secondary outcome).ResultsAmong 338 ICU patients, 94 (28%) were colonized with either Ceph-R or CRE. 26 patients developed CRE infection within 30 days of swab collection; 47% (N = 17/36) of CRE-colonized and 3% (N = 2/58) of Ceph-R colonized patients. 36% (N = 13/36) of CRE-colonized patients died within 90 days compared to 31% (N = 18/58) of Ceph-R-colonized and 15% (N = 37/244) of non-colonized patients. In a multivariable analysis, CRE colonization independently predicted development of a systemic CRE infection at 30 days (aOR 10.8, 95% CI2.8–41.9, p = 0.0006); Ceph-R colonization did not (aOR 0.5, 95% CI0.1–3.3, p = 0.5). CRE colonization was associated with increased 90-day mortality in a univariable analysis (p-value 0.001), in a multivariable model, previous hospitalization and medical ICU admission were independent predictors of 90-day mortality whereas CRE colonization approached significance (aOR 2.3, 95% CI1.0–5.3, p = 0.056).ConclusionsOur study highlights the increased risk of CRE infection and mortality in patients with CRE colonization at the time of ICU admission. Future studies are needed to assess how CRE colonization can guide empiric antibiotic choices and to develop novel decolonization strategies.

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Section: Discussionmentioning

confidence: 99%

Carbapenem-resistant Enterobacteriaceae colonization (CRE) and subsequent risk of infection and 90-day mortality in critically ill patients, an observational study

et al. 2017

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“…Fecal transplantation to restore a healthy microbial environment is a potential novel strategy that should be further explored. (10) Neither method, though, would address colonization at other sites of the body or prevent recolonization with the same MDR organism due to ongoing exposures. Lastly, what is the benefit of adjusting perioperative prophylaxis targeting the colonizing MDR organism?…”

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confidence: 99%

The evolving threat of carbapenem‐resistant infections after liver transplantation: The case of A cinetobacter baumannii

Pereira

Uhlemann

2016

Liver Transpl

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Postoperative bacterial infections have shifted from predominantly gram-positive to gram-negative organisms in liver transplantation (LT) recipients.(1) Of concern is the increasing incidence of difficult to treat multidrug resistant (MDR) infections due to extended spectrum b-lactamases and carbapenemresistant Enterobacteriacae. The high mortality rate (40%-70%) associated with post-LT carbapenemresistant Klebsiella pneumoniae (CRKP) infections is a sobering example of the impact of MDR infection in this population. (2,3) In this issue of Liver Transplantation, Freire et al. (4) provide compelling evidence that an additional organism, carbapenem-resistant Acinetobacter baumannii (CRAB), is also associated with very high morbidity and mortality after LT. In a prospective 2-year cohort study, the authors routinely surveyed colonization with A. baumannii at 3 body sites (rectum, throat, and axilla) immediately prior to LT and weekly thereafter until hospital discharge. Of the 196 LT recipients evaluated, 105 (54%) were found to have acquired CRAB, most often (n 5 81) during the post-LT period. Similarly, although 60 recipients developed CRAB infection, the majority of these (n 5 56) occurred post-LT and usually early in the post-LT course (median time, 9 days; range, 1-43 days). The likelihood of post-LT CRAB acquisition increased with retransplantation within 60 days after LT and prior use of piperacillintazobactam or a carbapenem. Most notably, 60-day mortality in the recipients with CRAB infection was 46.4%. Risk factors associated with 60-day mortality included LT for acute liver failure, need for post-LT dialysis, prolonged cold ischemia time, and a trend toward significance for pre-LT CRAB acquisition. Molecular typing by pulsed-field gel electrophoresis (PFGE) analysis revealed that 71% of infected recipients had 1 predominant strain, suggesting a clonal outbreak in the LT unit or across the hospital. Importantly, a series of infection control measures including weekly surveillance cultures, contact precautions, contact isolation of CRAB-colonized patients, hand hygiene training, and systematic discussions of CRAB cases attributed to the unit resulted in the incidence of CRAB acquisition dropping from 12.2/1000 patient-days in 2009 to 5.5/1000 patient-days by 2014.Although these findings are remarkable, some aspects of the conclusions should be interpreted with caution. For instance, this study was performed during an outbreak, perhaps limiting its applicability. It also remains unclear if this was solely an outbreak in the LT unit or represented a hospital-wide outbreak. In addition, although the crude 60-day mortality was very high, determining the attributable mortality of post-LT CRAB infections is difficult. In prior studies that rigorously controlled for severity of illness, A. baumannii infection was not independently associated with increased mortality, raising the possibility that this organism is a marker of increased severe underlying illness rather than an independent predictor of mortality. (5,...

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“…Exposure of gut microbiota to ATBs is known to reduce microbial susceptibility to drugs and can induce development of MDR microorganisms [ 27 , 28 ]. Of note, ATBs can impair the ecology of commensal species, leading to a reduction of intrinsic colonization resistance and contributing to the transmission of ATB resistance mechanisms, such as lateral transfer of resistance genes [ 29 , 30 ].…”

Section: Review and Discussionmentioning

confidence: 99%

Liver Transplantation and Gut Microbiota Profiling in a Child Colonized by a Multi-Drug Resistant Klebsiella pneumoniae: A New Approach to Move from Antibiotic to “Eubiotic” Control of Microbial Resistance

Chierico

Cardile

Pietrobattista

et al. 2018

IJMS

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The increase of microorganisms multi-drug resistant (MDR) to antibiotics (ATBs) is becoming a global emergency, especially in frail subjects. In chronic liver disease (LD) with indications for liver transplantation (LT), MDR colonization can significantly affect the LT outcome. However, no clear guidelines for microbial management are available. A novel approach toward MDR-colonized patients undergoing LT was developed at our Center refraining from ATBs use during the transplant waiting list, and use of an intensive perioperative prophylaxis cycle. This study aimed to couple clinical evaluation with monitoring of gut microbiota in a pediatric LD patient colonized with MDR Klebsiella pneumoniae (KP) who underwent LT. No peri-transplant complications were reported, and a decontamination from the MDR bacteria occurred during follow-up. Significant changes in gut microbiota, especially during ATB treatment, were reported by microbiota profiling. Patterns of Klebsiella predominance and microbiota diversity revealed opposite temporal trends, with Klebsiella ecological microbiota niches linked to ATB-driven selection. Our infection control program appeared to control complications following LT in an MDR-KP-colonized patient. The perioperative ATB regimen, acting as LT prophylaxis, triggered MDR-KP overgrowth and gut dysbiosis, but buffered infectious processes. Mechanisms modulating the gut ecosystem should be taken into account in MDR colonization clinical management.

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Intestinal decontamination of multidrug-resistant Klebsiella pneumoniae after recurrent infections in an immunocompromised host

Cited by 13 publications

References 15 publications

Carbapenem-resistant Enterobacteriaceae colonization (CRE) and subsequent risk of infection and 90-day mortality in critically ill patients, an observational study

Carbapenem-resistant Enterobacteriaceae colonization (CRE) and subsequent risk of infection and 90-day mortality in critically ill patients, an observational study

The evolving threat of carbapenem‐resistant infections after liver transplantation: The case of A cinetobacter baumannii

Liver Transplantation and Gut Microbiota Profiling in a Child Colonized by a Multi-Drug Resistant Klebsiella pneumoniae: A New Approach to Move from Antibiotic to “Eubiotic” Control of Microbial Resistance

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