Impacto de la multirresistencia en la patogenicidad de Pseudomonas aeruginosa: perspectiva epidemiológica-clinica y experimental

[spa] P. aeruginosa es uno de los principales patógenos nosocomiales y posee una gran capacidad de desarrollar resistencias a los antimicrobianos con la emergencia de cepas multirresistentes (MDR) y extremadamente resistentes (XDR). En las últimas décadas se ha producido un incremento de las infecciones por cepas multirresistentes que plantea la necesidad de desarrollar estrategias de control de infección y un uso prudente de los antimicrobianos. En este contexto se desarrolla la presente tesis doctoral en la que se incluyen ocho trabajos publicados en revistas científicas, que están encaminados tanto a mejorar el conocimiento epidemiológico de P. aeruginosa como a evaluar el impacto de la multirresistencia en la patogenicidad y virulencia de P. aeruginosa desde una perspectiva clínica, epidemiológica y experimental. La posible existencia de un coste biológico asociado a la multirresistencia supondría una menor virulencia de las cepas multirresistentes y podría justificar un uso más selectivo de las antibioticoterapias empíricas. Este proyecto doctoral incluye un estudio retrospectivo de neumonías asociada a ventilación mecánica por P. aeruginosa en el que se demostró que la mortalidad precoz era superior en las causadas por cepas no multirresistentes que en aquellas causadas por cepas multirresistentes. En un segundo estudio retropectivo, se identificó el consumo de fluoroquinolonas como principal factor de riesgo para el desarrollo de bacteriemia por P. aeruginosa XDR. Esta tesis incluye un estudio observacional prospectivo en el que se realizó vigilancia activa de colonización intestinal y de infección por P. aeruginosa. Gracias a este estudio se demostró que: 1) la colonización intestinal por cepas de P. aeruginosa MDR es más tardía que la colonización por cepas sensibles; 2) el consumo previo de fluoroquinolonas y carbapenémicos son los principales factores de riesgo para la colonización por P. aeruginosa multirresistente; 3) la colonización intestinal es un requerimiento clave para el desarrollo posterior de infección por P. aeruginosa; 4) la invasividad clínica fue mayor en las cepas no multirresistentes que en las multirresistentes, desarrollando los pacientes colonizados por cepas de P. aeruginosa no multirresistente con más frecuencia y precocidad infección que aquellos colonizados por cepas multirresistentes policlonales; 5) la intensidad de la respuesta inflamatoria se asoció con la severidad de la infección por P. aeruginosa, especialmente en infecciones bacteriémicas y 6) la respuesta inflamatoria fue superior en las infecciones por P. aeruginosa XDR en las que había un mayor porcentaje de infecciones bacteriémicas. En esta tesis también se incluye un estudio multicéntrico de pacientes con bacteriemia por P. aeruginosa se investigaron los genotipos del sistema de secreción tipo III y su relación con el pronóstico de los pacientes; demostrándose que el genotipo exoU+ es uno de los principales determinantes de virulencia de P. aeruginosa y se asocia a una mayor mortalidad precoz. Este genotipo fue más frecuente en los fenotipos no multirresistentes que en los multirresistentes. Finalmente, mediante un modelo experimental in vitro e in vivo se evaluó el impacto de la multirresistencia en la patogenicidad y virulencia de P. aeruginosa. En el modelo de peritonitis-sepsis murino se observó que las cepas multirresistentes presentaron menor capacidad de producir infección localizada y diseminada, menor capacidad de producir respuesta inflamatoria y menor mortalidad que las cepas sensibles. En conjunto, nuestros resultados sugieren que las cepas de Pseudomonas aeruginosa multirresistente producen una colonización más tardía y sufren un coste biológico, manifestado con una menor tasa de crecimiento in vitro, una menor invasividad clínica, una menor capacidad de producir respuesta inflamatoria y una menor mortalidad atribuible de las cepas multirresistentes. Esto permite considerar un mayor margen en el abordaje empírico de estas situaciones clínicas y una utilización más ajustada de la antibioterapia.[eng] Pseudomonas aeruginosa is one of the most common nosocomial pathogens worldwide, and continuously evolving resistance to multiple antimicrobial agents has become a significant health problem. However, the biological implications of antibiotic resistance on the pathogenicity and virulence of P. aeruginosa are not clearly established. It is believed that acquisition of resistance mechanisms may have a negative impact on bacterial fitness (a fitness cost), resulting in impaired bacterial physiology and, in turn, a loss of virulence. Improve knowledge about the possible biological cost associated with resistance may help to implement infection control strategies as well as improve antibiotic prescription. In this context, this doctoral thesis evaluates the impact of multidrug resistance on the pathogenicity of P. aeruginosa through epidemiological, clinical and experimental studies. Using clinical and epidemiological data, we investigated if there were differences in the outcome, in the ability to develop colonization and infection between multidrug resistant (MDR) and non-MDR P. aeruginosa strains. In a retrospective study we observed that early mortality was higher in ventilator-associated pneumonia caused by non-MDR P. aeruginosa than those caused by MDR strains. In a prospective study we demonstrated that intestinal colonization occurred more prematurely for non-MDR P. than for MDR isolates. The ability to produce infection (clinical invasiveness) was also higher in patient colonized by non-MDR isolates than those colonized by MDR strains. Furthermore, using in vitro and in vivo models we demonstrated that MDR profiles were associated with a reduction in virulence of P. aeruginosa. In vitro growth rate was shorter in non-MDR than in MDR isolates. In a mice peritonitis/sepsis model we observed that non-MDR P. aeruginosa isolates had a greater ability to produce infection, to elicit inflammatory response and to cause mortality than MDR strains. Overall, our data suggest that multidrug resistance is associated with a biological cost in P. aeruginosa

Impact of generic entry on hospital antimicrobial use: a retrospective quasi-experimental interrupted time series analysis

Background: the impact of antimicrobials generic entry (GE) is controversial. Their introduction could provide an economic benefit yet may also increase their consumption, leadingto a higher risk of resistance. Our aim was to analyze the impact of GE on trends of antimicrobialconsumption in an acute-care hospital. Methods: a retrospective quasi-experimental interrupted timeseries analysis was conducted at a 400-bed tertiary hospital in Barcelona, Spain. All antimicrobials forsystemic use for which a generic product entered the hospital from January 2000 to December 2019 were included. Antimicrobial consumption was expressed as DDD/100 bed days. Results: after GE, the consumption of cefotaxime (0.09,p< 0.001), meropenem (0.54,p< 0.001), and piperacillin-tazobactam (0.13,p< 0.001) increased, whereas the use of clindamycin (−0.03,p< 0.001) anditraconazole (−0.02,p= 0.01) was reduced. An alarming rise in cefepime (0.004), daptomycin (1.02),and cloxacillin (0.05) prescriptions was observed, despite not achieving statistical significance. Onthe contrary, the use of amoxicillin (−0.07), ampicillin (−0.02), cefixime (−0.06), fluconazole (−0.13),imipenem-cilastatin (−0.50) and levofloxacin (−0.35) decreased. These effects were noticed beyondthe first year post GE. Conclusions: GE led to an increase in the consumption of broad-spectrummolecules. The potential economic benefit of generic antibiotics could be diluted by an increase inresistance. Antimicrobial stewardship should continue to monitor these molecules despite GE

Streptococcus suis infection and malignancy in man, Spain

Streptococcus suis is an emerging zoonotic agent. Human infection is associated with occupational exposure to swine. Affected persons are usually, but not always, healthy (1,2). Immunosuppressive conditions can predispose persons to S. suis infection, and cancer has classically been associated as a risk factor for S. suis infection (1,2). Nevertheless, the actual number of reported cases is low (27). We describe a severe case of S. suis infection in a man who had not been exposed to swine but for whom disseminated cancer was diagnosed 5 months after the infection

Acute inflammatory response of patients with Pseudomonas aeruginosa infections: a prospective study

The severity of Pseudomonas aeruginosa (PA) infection may be determined by the interaction with the host immune system. We designed a prospective study to assess the relationship between the inflammatory response and the clinical presentation and outcome of PA infection. We also investigated whether there are differences in the inflammatory response depending on the resistance profile of PA. Interleukin-6 (IL-6), IL-10, procalcitonin (PCT), and C-reactive protein (CRP) were measured. Sixty-nine infection episodes were recorded; 40 caused by non-multidrug-resistant (non-MDR) strains [29 (73%) respiratory; 8 (20%) bacteremia], 12 by MDR non-extensively drug-resistant (MDR-non-XDR) [9 (75%) respiratory; 3 (25%) bacteremia], and 17 by XDR strains [9 (53%) respiratory; 7 (41%) bacteremia]. All inflammatory parameters were significantly higher in patients who developed acute organ dysfunction and bacteremia. PCT levels were higher in patients with early mortality [p = 0.050]. Inflammatory biomarkers were higher in patients with XDR than in those with non-MDR PA [IL-6 430 (67-951) vs. 77 (34-216), p = 0.02; IL-10 3.3 (1.5-16.3) vs. 1.3 (0-3.9), p = 0.02; and PCT 1.1 (0.6-5.2) vs. 0.3 (0.1-1.0), p = 0.008]. The intensity of inflammatory response was associated with the severity of PA infection, particularly if bacteremia occurred. Only PCT was documented useful to predict the outcome. XDR infections presented a higher inflammatory response; related in part to the larger number of bloodstream infections in this group

Genomics And Susceptibility Profiles Of Extensively Drug-resistant Pseudomonas Aeruginosa Isolates From Spain

This study assessed the molecular epidemiology, resistance mechanisms, and susceptibility profiles of a collection of 150 extensively drug-resistant (XDR) Pseudomonas aeruginosa clinical isolates obtained from a 2015 Spanish multicenter study, with a particular focus on resistome analysis in relation to ceftolozane-tazobactam susceptibility. Broth microdilution MICs revealed that nearly all (> 95%) of the isolates were nonsusceptible to piperacillin-tazobactam, ceftazidime, cefepime, aztreonam, imipenem, meropenem, and ciprofloxacin. Most of them were also resistant to tobramycin (77%), whereas nonsusceptibility rates were lower for ceftolozane-tazobactam (31%), amikacin (7%), and colistin (2%). Pulsed-field gel electrophoresis-multilocus sequence typing (PFGE-MLST) analysis revealed that nearly all of the isolates belonged to previously described high-risk clones. Sequence type 175 (ST175) was detected in all 9 participating hospitals and accounted for 68% (n = 101) of the XDR isolates, distantly followed by ST244 (n = 16), ST253 (n = 12), ST235 (n = 8), and ST111 (n = 2), which were detected only in 1 to 2 hospitals. Through phenotypic and molecular methods, the presence of horizontally acquired carbapenemases was detected in 21% of the isolates, mostly VIM (17%) and GES enzymes (4%). At least two representative isolates from each clone and hospital (n = 44) were fully sequenced on an illumina MiSeq. Classical mutational mechanisms, such as those leading to the overexpression of the beta-lactamase AmpC or efflux pumps, OprD inactivation, and/or quinolone resistance-determining regions (QRDR) mutations, were confirmed in most isolates and correlated well with the resistance phenotypes in the absence of horizontally acquired determinants. Ceftolozane-tazobactam resistance was not detected in carbapenemase-negative isolates, in agreement with sequencing data showing the absence of ampC mutations. The unique set of mutations responsible for the XDR phenotype of ST175 clone documented 7 years earlier were found to be conserved, denoting the long-term persistence of this specific XDR lineage in Spanish hospitals. Finally, other potentially relevant mutations were evidenced, including those in penicillin-binding protein 3 (PBP3), which is involved in beta-lactam (including ceftolozane-tazobactam) resistance, and FusA1, which is linked to aminoglycoside resistance

Multicentre, randomised, open-label, phase IV-III study to evaluate the efficacy of cloxacillin plus fosfomycin versus cloxacillin alone in adult patients with methicillin-susceptible Staphylococcus aureus bacteraemia: study protocol for the SAFO trial

Introduction: Methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia is a frequent condition, with high mortality rates. There is a growing interest in identifying new therapeutic regimens able to reduce therapeutic failure and mortality observed with the standard of care of beta-lactam monotherapy. In vitro and small-scale studies have found synergy between cloxacillin and fosfomycin against S. aureus. Our aim is to test the hypothesis that cloxacillin plus fosfomycin achieves higher treatment success than cloxacillin alone in patients with MSSA bacteraemia. Methods: We will perform a superiority, randomised, open-label, phase IV-III, two-armed parallel group (1:1) clinical trial at 20 Spanish tertiary hospitals. Adults (≥18 years) with isolation of MSSA from at least one blood culture ≤72 hours before inclusion with evidence of infection, will be randomly allocated to receive either cloxacillin 2 g/4-hour intravenous plus fosfomycin 3 g/6-hour intravenous or cloxacillin 2 g/4-hour intravenous alone for 7 days. After the first week, sequential treatment and total duration of antibiotic therapy will be determined according to clinical criteria by the attending physician. Primary endpoints: (1) Treatment success at day 7, a composite endpoint comprising all the following criteria: patient alive, stable or with improved quick-Sequential Organ Failure Assessment score, afebrile and with negative blood cultures for MSSA at day 7. (2) Treatment success at test of cure (TOC) visit: patient alive and no isolation of MSSA in blood culture or at another sterile site from day 8 until TOC (12 weeks after randomisation). We assume a rate of treatment success of 74% in the cloxacillin group. Accepting alpha risk of 0.05 and beta risk of 0.2 in a two-sided test, 183 subjects will be required in each of the control and experimental groups to obtain statistically significant difference of 12% (considered clinically significant). Ethics and dissemination: Ethical approval has been obtained from the Ethics Committee of Bellvitge University Hospital (AC069/18) and from the Spanish Medicines and Healthcare Product Regulatory Agency (AEMPS, AC069/18), and is valid for all participating centres under existing Spanish legislation. The results will be presented at international meetings and will be made available to patients and funders

Suspected acute pulmonary embolism in patients with and without cancer: alternative diagnoses

Objetivo: conocer los diagnósticos alternativos al tromboembolismo pulmonar (TEP) en los pacientes oncológicos y no oncológicos atendidos en un servicio de urgencias hospitalario (SUH) a los que se les solicitó una tomografía computarizada (TC). Método: estudio retrospectivo con inclusión de todos los pacientes a los que se les practicó una TC desde un SUH por sospecha de TEP durante los años 2006 y 2007. Resultados: se incluyeron un total de 265 pacientes, 93 oncológicos y 172 no oncológicos. El 98,5% presentaban, o bien una sospecha clínica alta de acuerdo a las escalas de Wells y de Geneva, o bien una sospecha clínica baja o intermedia con una determinación de dímero D positiva. En los pacientes oncológicos y no oncológicos, el porcentaje de diagnosticados de TEP fue del 25,8% y 39,5%, respectivamente. En los pacientes con sospecha de TEP en los que éste no se confirmó, la TC permitió determinar el diagnóstico alternativo en el 81,2% de los pacientes oncológicos y en el 67,3% de los no oncológicos. En los oncológicos el diagnóstico alternativo más frecuente fue la progresión neoplásica, que incluso fue más frecuente que el de TEP. Los diagnósticos alternativos más frecuentes en los no oncológicos, fueron la insuficiencia cardiaca aguda (ICA), la enfermedad pulmonar obstructiva crónica (EPOC) descompensada y la neumonía. Conclusiones: en los pacientes con sospecha de TEP, la TC permitió determinar el diagnóstico alternativo en un elevado porcentaje de pacientes. Los diagnósticos alternativos más frecuentes fueron la progresión neoplásica en los pacientes oncológicos y la EPOC descompensada y la ICA en los no oncológicos

Factors associated with recruitment success in the phase 2a study of aztreonam-avibactam development programme: a descriptive qualitative analysis among sites in Spain

Objective: Successful clinical trials are subject to recruitment. Recently, the REJUVENATE trial, a prospective phase 2a open-label, single-arm interventional clinical trial conducted within the Innovative Medicines Initiative-supported Combatting Bacterial Resistance in Europe-Carbapenem Resistance project, was published, with 85% of the recruitment performed in Spain. We analysed the recruitment success in this trial by establishing a model of recruitment practice. Methods: A descriptive qualitative study was performed from May 2016 to October 2017 at 10 participating Spanish centres. Data were extracted from: (1) feasibility questionnaires to assess the centre's potential for patient enrolment; (2) delegation of responsibility records; (3) pre-screening records including an anonymised list of potentially eligible and (4) screening and enrolment records. A descriptive analysis of the features was performed by the participating centre. Pearson's and Spearman's correlation coefficients were calculated to determine factors of recruitment success. Results: The highest recruitment rate was observed in Hospitals 3 and 6 (58.8 and 47.0 patients per month, respectively). All the study teams were multidisciplinary with a median of 15 members (range: 7-22). Only Hospitals 3, 5 and 6 had dedicated nursing staff appointed exclusively to this study. Moreover, in those three hospitals and in Hospital 9, the study coordinator performed exclusive functions as a research planner, and did not assume these functions for the other hospitals. The univariate analysis showed a significant association between recruitment success and months of recruitment (p=0.024), number of staff (p<0.001), higher number of pharmacists (p=0.005), infectious disease specialists (p<0.001), the presence of microbiologist in the research team (p=0.018) and specifically dedicated nursing staff (p=0.036). Conclusions: The existence of broad multidisciplinary teams with staff dedicated exclusively to the study as well as the implementation of a well-designed local patient assessment strategy were the essential optimisation factors for recruitment success in Spain. Trial registration number: NCT02655419; EudraCT 2015-002726-39; analysis of pre-screened patients

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research