Post-surgical mediastinitis due to carbapenem-resistant Enterobacteriaceae: Clinical, epidemiological and survival characteristics

Abboud, Cely Saad; Monteiro, Jussimara; Stryjewski, Martín E.; Zandonadi, E.C.; Barbosa, Vera Lúcia; Dantas, Daniel Chagas; Sousa, Ercilia Evangelista de; Fonseca, Michele Pereira de Souza da; Jacobs, David M.; Pignatari, Antônio Carlos Campos; Kiffer, Carlos Roberto Veiga; Rao, Gauri G.

doi:10.1016/j.ijantimicag.2016.02.015

Cited by 21 publications

(20 citation statements)

References 19 publications

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“…Among the Gram-negative bacteria, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter cloacae exhibited 100%, 15% and 0% resistance to ceftazidime, respectively, 100%, 22.5% and 40% resistance to piperacillin-tazobactam, respectively, and 80%, 17.5% and 0% resistance to carbapenem, respectively [33]. In a Brazilian series including 92 individuals with post-cardiac surgery mediastinitis [34], 33 (35.8%) were infected with carbapenem-resistant Enterobacteriaceae, among whom 15 (45%) were also resistant to colistin. The discrepancy between the different cultures and sensitivities of the microbiological flora identified may be explained by local ecologies and institutional antibiotic policies.…”

Section: Mediastinitis After Cardiac Surgerymentioning

confidence: 97%

Mediastinitis in the intensive care unit patient: a narrative review

Pastène

Cassir

Tankel

et al. 2020

Clinical Microbiology and Infection

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Background: Mediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity to vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit. Objectives: To highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatments. Sources: We performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis. Content: The term covers different entities of different aetiologies including deep sternal wound infection related to sternotomy; oesophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis, often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying aetiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement. Implications: Literature concerning mediastinitis in the intensive care unit is relatively scarce. We have collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease.

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Section: Mediastinitis After Cardiac Surgerymentioning

confidence: 97%

Mediastinitis in the intensive care unit patient: a narrative review

Pastène

Cassir

Tankel

et al. 2020

Clinical Microbiology and Infection

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“…2 Posttraumatic or post-operative osteomyelitis and prosthetic joint infection (PJI) due to CPE have been more recently described in countries where CPE is endemic or in hospitals receiving patients from endemic areas. 3,4 Treatment of these infections is especially difficult because they present a combination of the main current challenges in the field of antibiotics. First, despite the recent approval of new compounds, such as ceftazidime/ avibactam, therapeutic options remain scarce and could rely on old antibacterial agents with limited clinical data on their efficacy and a high risk of adverse events.…”

Section: Introductionmentioning

confidence: 99%

Efficacy of colistin alone and in various combinations for the treatment of experimental osteomyelitis due to carbapenemase-producing Klebsiella pneumoniae

Crémieux

Dinh

Nordmann

et al. 2019

Journal of Antimicrobial Chemotherapy

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Objectives In a new experimental model of carbapenemase-producing Klebsiella pneumoniae osteomyelitis we evaluated the efficacy of colistin alone and in various combinations and examined the emergence of colistin-resistant strains and cross-resistance to host defence peptides (HDPs). Methods KPC-99YC is a clinical strain with intermediate susceptibility to meropenem (MIC = 4 mg/L) and full susceptibility to gentamicin, colistin and tigecycline (MICs = 1 mg/L) and fosfomycin (MIC = 32 mg/L). Time–kill curves were performed at 4× MIC. Osteomyelitis was induced in rabbits by tibial injection of 2 × 108 cfu. Treatment started 14 days later for 7 days in seven groups: (i) control; (ii) colistin; (iii) colistin + gentamicin; (iv) colistin + tigecycline; (v) colistin + meropenem; (vi) colistin + meropenem + gentamicin; and (vii) colistin + fosfomycin. Results In vitro, colistin was rapidly bactericidal, but regrowth occurred after 9 h. Combinations of colistin with meropenem or fosfomycin were synergistic, whereas combination with tigecycline was antagonistic. In vivo, colistin alone was not effective. Combinations of colistin with meropenem or fosfomycin were bactericidal (P < 0.001) and the addition of gentamicin enhanced the efficacy of colistin + meropenem (P = 0.025). Tigecycline reduced the efficacy of colistin (P = 0.007). Colistin-resistant strains emerged in all groups except colistin + fosfomycin and two strains showed cross-resistance to HDP LL-37. Conclusions In this model, combinations of colistin plus meropenem, with or without gentamicin, or colistin plus fosfomycin were the only effective therapies. The combination of colistin and tigecycline should be administered with caution, as it may be antagonistic in vitro and in vivo.

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“…Nevertheless, these outcomes are very serious because the burden suffered from CRE SSTIs is high. Abboud et al [ 8 ] described a cohort of 33 patients with postsurgical mediastinitis due to CRE, mainly CRKP. The mortality rate was higher in their cohort (33%) probably due to the poor outcomes associated with mediasinits [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

A Prospective Observational Study of the Epidemiology, Management, and Outcomes of Skin and Soft Tissue Infections Due to Carbapenem-Resistant Enterobacteriaceae

Henig

Cober²,

Richter

et al. 2017

Open Forum Infectious Diseases

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BackgroundThis study was performed to characterize the epidemiology, management, and outcomes of skin and soft tissue infection (SSTI) and colonization due to carbapenem-resistant Enterobacteriaceae (CRE).MethodsPatients from the Consortium on Resistance Against Carbapenem in Klebsiella and Other Enterobacteriaceae (CRACKLE-1) from December 24, 2011 to October 1, 2014 with wound cultures positive for CRE were included in the study. Predictors of surgical intervention were analyzed. Molecular typing of isolates was performed using repetitive extragenic palindromic polymerase chain reaction (PCR). Carbapenemase genes were detected using PCR.ResultsOne hundred forty-two patients were included: 62 had SSTI (44%) and 56% were colonized. Mean age was 61 years, and 48% were male: median Charlson score was 3 (interquartile range, 1–5). Forty-eight percent of patients were admitted from long-term care facilities (LTCFs), and 31% were from the community. Two strain types (ST258A and ST258B) were identified (73% of 45 tested). Carbapenemase genes were detected in 40 of 45 isolates (blaKPC-3 [47%], blaKPC-2 [42%]). Sixty-eight patients (48%) underwent surgical intervention, 63% of whom had SSTI. Patients admitted from LTCFs were less likely to undergo surgical intervention (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.18–0.71). In multivariable analysis, among patients with SSTI, those admitted from LTCFs were less likely to undergo debridement (OR, 0.18; 95% CI, 0.04–0.93).ConclusionsPatients admitted from LTCFs with CRE SSTI were less likely to undergo surgical intervention. Sixteen percent of the patients died, and approximately 50% of survivors required more intensive care upon discharge. These findings suggest a unique, impactful syndrome within the CRE infection spectrum. Further studies are needed to assess the role of surgical debridement in management of CRE-SSTI, particularly among LTCF residents.

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Post-surgical mediastinitis due to carbapenem-resistant Enterobacteriaceae: Clinical, epidemiological and survival characteristics

Cited by 21 publications

References 19 publications

Mediastinitis in the intensive care unit patient: a narrative review

Mediastinitis in the intensive care unit patient: a narrative review

Efficacy of colistin alone and in various combinations for the treatment of experimental osteomyelitis due to carbapenemase-producing Klebsiella pneumoniae

A Prospective Observational Study of the Epidemiology, Management, and Outcomes of Skin and Soft Tissue Infections Due to Carbapenem-Resistant Enterobacteriaceae

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