Transcript C-Girmeniax

Le infezioni batteriche nel
paziente oncoematologico
Corrado Girmenia
Ematologia, Azienda Policlinico Umberto I
Sapienza University of Rome, Italy
Ematologia
P. aeruginosa resistance (Europe, 2013)
AMG
CAZ
NEM
FQs
PTZ
MDR
EARS-NET
Resistance to third-generation cephalosporins (ESBL)
Europe, 2013
Overall
EU trend
K. pneumoniae
E. coli
Overall
EU trend
EARS-NET
2013
EARS-NET Maps. Available at: www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/map_reports.aspx.
Accessed November2014. EARS-NET Tables. Available at: www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/table_reports.aspx. Accessed November 2014.
Carbapenem-resistant Klebsiella pneumoniae –
Europe
Percentage resistance
<1%
1 to <5%
5 to <10%
10 to <25%
25 to <50%
≥50%
No data reported or
<10 isolates
Not included
2009
2013
EARS-NET
CPE are endemic in
Italy and Greece!!!
MDR and XDR Gram negative
bacteria in hematologic population
www.ebmt.org/events
Pagano et al. Emerg Infect Dis 2014
57.6% mortality rate
Current epidemiology and antimicrobial resistance data for
bacterial bloodstream infections in patients with hematologic
malignancies: an Italian multicentre prospective survey
Trecarichi et al CMI 2015
• Prospective cohort study, nine Italian hematology wards, January
2009 to December 2012
• A total of 668 bacterial isolates were recovered in 575 BBSI.
• Gram neg/Gram pos: 57%/43%
• susceptibility rates of Gram-negative bacteria were 59.1% to
ceftazidime, 20.1% to ciprofloxacin, 79.1% to meropenem, 85.2%
to amikacin, 69.2% to gentamicin and 69.8% to
piperacillin/tazobactam.
• Resistance to 3rd gener. Cephalosporins: 36.9% of
Enterobacteriaceae
• Among Klebsiella pneumoniae strains, 34.9% were carba resistant
• Of 66 Pseudomonas aeruginosa isolates, 69.7% were MDR
• 21 day mortality rate: Gram neg 16.9%, Gram pos 5.6%
• the mortality rate was significantly higher for BBSI caused
by K. pneumoniae, P. aeruginosa, and Acinetobacter baumannii
49.8%
vs
74.7%;
p<0.001
6058 auto-SCTs
(54% of all transpl.)
4389 allo_SCTs
(72% of all transpl.)
A prospective, multicenter survey of Severe
Infections by Gram Negative Bacteria in patients
submitted to autologous and allogeneic stem cell
transplant.
(ClinicalTrials.gov, ID
NCT02088840)
Protocol code: SIGNB (Severe Infections by Gram Negative Bacteria)
GITMO-AMCLI Survey
1 Jan 2014-31 Dec 2014
55 transplant centers
Engraftment phase
Follow-up at 4 months from transplant
Cases enrolled: 1626 auto-SCT and 1121 allo-SCT
A prospective, multicenter survey of Severe
Infections by Gram-Negative Bacteria in patients
submitted to autologous and allogeneic SCT
(ClinicalTrials.gov,ID NCT02088840)
Preliminary data: 2714 evaluable cases
Auto-SCT
Allo-SCT
1618
1096
No fever or infection
676 (42%)
281 (26%)
FUO only
468 (29%)
374 (34%)
88 (5.4%)
61 (5.6%)
386 (24%)
370 (34%)
Gram-positive infections*
203 (12.4%)
223 (20%)
Gram-negative infections*
184 (11.4%)
163 (14.9%)
10 (0.6%)
23 (2.1%)
4 (0.2%)
39 (3.6%)
Total transplants
Clin. documented infections only *
Microb. documented infections*
Fungal infections*
Viral infections*
*cases with one or more infections
A prospective, multicenter survey of Severe
Infections by Gram-Negative Bacteria in patients
submitted to autologous and allogeneic SCT
(ClinicalTrials.gov,ID NCT02088840)
No. of isolates
120
Gram-negative isolates and resistance patterns:
190 isolates from Auto-SCT, 176 isolates from Allo-SCT
ESC-R
26%
ESC-R
33%
100
80
60
Carba-R
12%
40
ESC-R
54%
20
Carba-R
54%
ESC-R
19%
XDR
54%
XDR
50%
0
Auto-SCT
E.coli
K.pneumoniae
Allo-SCT
P.aeruginosa
Other
A prospective, multicenter survey of Severe
Infections by Gram-Negative Bacteria in patients
submitted to autologous and allogeneic SCT
(ClinicalTrials.gov,ID NCT02088840)
Correlation between colonization and infection by
MDR/XDR pathogens during engrafment
Auto-SCT
Allo-SCT
N. infections/total colonizations (%)
E. coli ESC-R
15/110 (14)
7/78
(9)
K. pneumoniae ESC-R
6/34
(18)
5/37 (13)
K. pneumoniae Carba-R
1/6
(17)
16/30 (53)
P. aeruginosa XDR
2/13
(15)
8/28 (29)
Risk factors for pre-engraftment Gram negative
infections in allogeneic SCT patients
• Age
• Type of donor
• Colonization by MDR Gram
negative
• Pre-transplant Gram negative
infection
A prospective, multicenter survey of Severe
Infections by Gram-Negative Bacteria in patients
submitted to autologous and allogeneic SCT
(ClinicalTrials.gov,ID NCT02088840)
16
Mortality at 4 months from transplant
13.5
% of all transplants
14
12
10
8
6
4
2
2.4
1
0.3
1.6
0.2
0
Auto-SCT, n. 1618
Overall mortality
Death due to XDR Kpn and Pae
Allo-SCT, n. 1096
Death due to Gram-neg
Out of 51 allo-SCT patients who died before the engraftment in 23
cases (45%) the cause of death was a Gram negative septicemia
Variabili indipendenti correlate alla probabilità
di sopravvivenza a 4 mesi dal trapianto
• Previous allogeneic SCT
• N. of pre transplant chemotherapy
lines
• Disease status at transplant
• Gram negative infection
Susceptibility of Klebsiella pneumoniae Isolates to
Carbapenems in Italy, France, Greece, Spain and Austria,
2009 - 2013 Country
Year
S
I
R
Total N
%S
%I
%R
Austria
2009
463
0
0
463
100.0 %
0.0 %
0.0 %
Austria
2010
506
0
3
509
99.4 %
0.0 %
0.6 %
Austria
2011
608
1
1
610
99.7 %
0.2 %
0.2 %
Austria
2012
727
5
6
738
98.5 %
0.7 %
0.8 %
Austria
2013
897
2
11
910
98.6 %
0.2 %
1.2 %
France
2009
1262
4
2
1268
99.5 %
0.3 %
0.2 %
France
2010
1428
3
1
1432
99.7 %
0.2 %
0.1 %
France
2011
1638
2
0
1640
99.9 %
0.1 %
0.0 %
France
2012
1610
9
8
1627
99.0 %
0.6 %
0.5 %
France
2013
1821
9
12
1842
98.9 %
0.5 %
0.7 %
Greece
2009
788
131
708
1627
48.4 %
8.1 %
43.5 %
Greece
2010
683
176
828
1687
40.5 %
10.4 %
49.1 %
Greece
2011
478
43
1115
1636
29.2 %
2.6 %
68.2 %
Greece
2012
549
28
883
1460
37.6 %
1.9 %
60.5 %
Greece
2013
479
12
718
1209
39.6 %
1.0 %
59.4 %
Italy
2009
300
0
4
304
98.7 %
0.0 %
1.3 %
Italy
2010
615
5
111
731
84.1 %
0.7 %
15.2 %
Italy
2011
433
18
164
615
70.4 %
2.9 %
26.7 %
Italy
2012
580
19
246
845
68.6 %
2.2 %
29.1 %
Italy
2013
930
24
499
1453
64.0 %
1.7 %
34.3 %
Spain
2009
574
0
1
575
99.8 %
0.0 %
0.2 %
Spain
2010
1161
0
0
1161
100.0 %
0.0 %
0.0 %
Spain
2011
1138
2
4
1144
99.5 %
0.2 %
0.3 %
Spain
2012
1136
7
9
1152
98.6 %
0.6 %
0.8 %
Spain
2013
1212
9
20
1241
97.7 %
0.7 %
1.6 %
Crucial issues in the infection-control of CR-KP and
other XDR infections:
1. Detection of carriers
2. Patients and staff coorting
3. Intrahospital strategy
4. Territorial intervention
5. Supervision by infection-control committee and
health policy agencies
ECCMID 2013; eP698
Prospective, cross-sectional observational study of hospitalised patients colonised with
carbapenemase resistant Klebsiella pneumoniae (CR-KP)
M. Bartoletti et al (Bologna, IT)
To compare the incidence and outcome of CR-KP infections
among patient cohorts
• Incidence N/1000 colonization days
–
–
–
–
–
–
medicine :4.3
Hematology: 26.3
ICU: 13.1
Surgical: 8.6
SOT: 7.4
Long Term Care: 4.7
Medicine departments:
Lowest risk of infection in CRKp colonized
Lowest risk of death in CRKp infections
• KPC-attributable mortality
–
–
–
–
–
–
Hematology:75%
ICU:11%
SOT:7%
LTC: 5%
Medicine: 2%
Surgery:2%
• In low risk departments CR-KP may be
perceived as a clinically not relevant
phenomenon.
• Low risk departments may represent the
occult reservoir of CR-KP!!!!
Eurosurveillance 2014
CPE Control program starting from 2004
• Local Infection Control Team was asked to report any new CPE case
documented in any department of the hospital to the Central
Infection Control Team
• For each event the LICT was asked to apply the following measures
– Day 1
• Nursing staff cohorting and barrier precautions
• Alert to the hospital administrator
• Stop of the transfers of the case and of contact patients to other units or
to other hospitals
• Screening of contact patients for CPE by culturing rectal swabs
– Day 2 and following days
• Extend CPE screening to contact patients already transferred from the
involved unit at the time of index case
• Contact patients transferred to other units only after 3 CPE negative
screening
• Cohorting as above for secondary cases
•
The CICT visited all the hospitals where an outbreack occurred to
help the local team to apply the programme
Eurosurveillance 2014
• 2006: several Israeli hospitals faced a clonal outbreak of
CRKp that was not controlled by local measures .
• March 2007: the Israeli Ministry of Health launched a
nationwide intervention and issued guidelines mandating
– patient and staff cohorting
– professional task force
site visits at acute-care hospitals,
evaluated infection-control policies and laboratory methods
supervised adherence to the guidelines
provided daily feedback on performance to hospital
directors
• made additional interventions when and where necessary.
•
•
•
•
79% relative reduction of the incidence
compared with the previous year
Infection control strategies in
SCT populations in an era of
antibiotic resistance
• Territorial surveillance,
dissemination of data
• Supervision of health
policy agencies
Territorial
Health
government
Interhospital
• Multidisciplinary,
interdepartment strategy
• Active supervision of the
infect-control committee
• Shared interhospital
infection-control strategy.
• Control of the patients
flows
Hospital
•
Department
•
•
•
•
Monitoring of MDR/XDR
colonization (rectal swab).
Contact-precautions
Trained nursing staff
Patients and staff cohorting
Tailored therapeuitc strategies