Le infezioni da patogeni MDR nel Paziente ematologico Corrado Girmenia Ematologia, Azienda Policlinico Umberto I Sapienza Università di Roma IT-NON-00443-WT-06-2021
Le infezioni da patogeni MDR nel Paziente ematologico
Corrado GirmeniaEmatologia, Azienda Policlinico Umberto I
Sapienza Università di Roma
IT-NON-00443-WT-06-2021
E.coliESBL
E.coliCR
K.pneumonieESBL
K.pneumonieCR
P.aeruginosaMDR Acinetobacter spp
MDR
Country Year Total N %RAustria 2009 463 0.0 %
2010 509 0.6 %2011 610 0.2 %2012 738 0.8 %2013 910 1.2 %2014 971 0.6 %2015 1022 0.8 %2016 1198 0.7 %2017 1109 1.0 %
France 2009 1268 0.2 %2010 1432 0.1 %2011 1640 0.0 %2012 1627 0.5 %2013 1842 0.7 %2014 2013 0.5 %2015 2244 0.5 %2016 2528 0.4 %2017 2807 0.7 %
Spain 2009 575 0.2 %2010 1161 0.0 %2011 1144 0.3 %2012 1152 0.8 %2013 1241 1.6 %2014 1266 2.3 %2015 1483 2.2 %2016 1677 2.1 %2017 1442 2,7 %
Resistance trend to carbapenems of Klebsiella pneumoniae Isolates in Italy, France, Greece, Spain and Austria, 2009 - 2017
Country Year Total N %RGreece 2009 1627 43.5 %
2010 1687 49.1 %2011 1636 68.2 %2012 1460 60.5 %2013 1209 59.4 %2014 1088 62.3 %2015 1185 61.9 %2016 1180 66.9 %2017 1363 64,7 %
Italy 2009 304 1.3 %2010 731 15.2 %2011 615 26.7 %2012 845 29.1 %2013 1453 34.3 %2014 1315 32.9 %2015 1999 33.5 %2016 2307 33.9 %2017 2634 29,7 %
Inter-regional diffusion, endemicity
KPC2008
KPC2007
OXA48
OXA48
OXA48
OXA48
OXA482010
OXA48
OXA48
OXA482001
KPC
E
EE
E
KPC2005
Geographic Distribution of NDM producersBiomed Res Int. 2014;2014:249856.4
Management of MDR/XDR-GNB in hematologic patients: key issues
• Is MDR/XDR-GNB frequent in hematologic patients?• Is mortality rate high in patients with MDR/XDR-
GNB?• Are there factors highly predictive of MDR/XDR-
GNB during neutropenia?• Are current antimicrobial treatments effective
against MDR/XDR-GNB?
Management of MDR/XDR-GNB in hematologic patients: key issues
• Is MDR/XDR-GNB frequent in hematologic patients?• Is mortality rate high in patients with MDR/XDR-
GNB?• Are there factors highly predictive of MDR/XDR-
GNB during neutropenia?• Are current antimicrobial treatments effective
against MDR/XDR-GNB?
Gram-negative isolates and resistance patterns: 157 isolates from Allo-SCT
0
10
20
30
40
50
60
70
80
90
E.coli, overall E.coli ESBLK.pneumoniae, overall K.pneumoniae ESBL no KPCK.pneumoniae KPC P.aeruginosa, overall
No.
of
isolat
es
E.coliESBL+39%
K.pn ESBL
+ KPC-26%
K.pn KPC+55%
P.aerMDR43%
OtherMDR17%
5/17 (29.4%) CRKp
resistant alsoto Colistin
E.coli
K.pnP.aer Other
Gram-negative isolates and resistance patterns: 162 isolates from Auto-SCT
0
20
40
60
80
100
120
E.coli, overall E.coli ESBLK.pneumoniae, overall K.pneumoniae ESBL no KPCK.pneumoniae KPC P.aeruginosa, overall
No.
of
isolat
es
E.coliESBL+29% K.pn
ESBL+
KPC-38%
K.pn KPC+27%
P.aerMDR14%
OtherMDR3%
No CRKpresistant also
to Colistin
E.coli
K.pnP.aer
Other
Clin Infect Dis 2017
Incidence of ESBL+CS-GNB in allo HSCT:• 36/149 (24%) GNBs• 36/1118 (3.2%) allo-HSCTsIncidence of CR-GNB in allo HSCT:• 28/149 (19%) GNBs• 28/1118 (2.5%) allo-HSCTs
Overall MDR/XDR• 43% of GNBs• 5.7% of allo-HSCTs
CMI 2015;21:337-43
E.coli CAZ-R:30%K.pneumoniae CAZ-R: 58%E.cloacae CAZ-R: 54%P.aeruginosa CAZ-R: 55%
K.pneumoniae carba-R: 35%P.aeruginosa carba-R: 71%
Management of MDR/XDR-GNB in hematologic patients: key issues
• Is MDR/XDR-GNB frequent in hematologic patients?• Is mortality rate high in patients with MDR/XDR-
GNB?• Are there factors highly predictive of MDR/XDR-
GNB during neutropenia?• Are current antimicrobial treatments effective
against MDR/XDR-GNB?
Probability of mortality at 4 months from transplant: Multivariate analysis
Allo-HSCT Auto-HSCT
Variable HR (95% CI), p
Variable HR (95% CI), p
Age (+10y) 1.10 (1.01-1.20) 0.03 Lymphoma vs other diseases 6.17 (2.78-1.6)<0.001
Other diseases vs acute leukemia
0.42 (0.29-0.63) <0.001 Phase of the und disease attransplant: noCR vs CR
4.8 (2.19-10.34), <0.001
Phase of the und disease attransplant: noCR vs CR
2.16 (1.47-3.15)<0.001
Pre transplant neutropenia 3.82 (1.80-8.12)0.001
Pre auto-HSCT 1.76 (1.19-2.63) 0.006 Days of pre engraftmentneutropenia (PMN<100/cmm)
1.07 (1.04-1.18)<0.001
Days of pre engraftmentneutropenia (PMN<100/cmm)
1.03(1.01-1.04) <0.001 Gram neg bacterial infection 2.43 (1.22-4.84)0.01
Acute II-IV GVHD 2.15 (1.21-3.82)0.009
Gram neg bacterial infection 2.13 (1.45-3.13)<0.001
Clin Infect Dis 2017
Management of MDR/XDR-GNB in hematologic patients: key issues
• Is MDR/XDR-GNB frequent in hematologic patients?• Is mortality rate high in patients with MDR/XDR-
GNB?• Are there factors highly predictive of MDR/XDR-
GNB during neutropenia?• Are current antimicrobial treatments effective
against MDR/XDR-GNB?
MDR/XDR GNB colonization and risk of pre-engraftment bacteremia
Management of MDR/XDR-GNB in hematologic patients: key issues
• Is MDR/XDR-GNB frequent in hematologic patients?• Is mortality rate high in patients with MDR/XDR-
GNB?• Are there factors highly predictive of MDR/XDR-
GNB during neutropenia?• Are current antimicrobial treatments effective
against MDR/XDR-GNB?
Challenging issues in the choice of antibiotic therapyin the light of MDR epidemiology in hematology
• Therapy of Carbapenem Resistant Enterobacteria infections
• Therapy of ESBL+ Enterobacteria infections
• Therapy of MDR P.aeruginosa infections
• When to start targeted antibiotic therapy: after microbiological documentationvs empirically
Haematologica 2013; 98 (12)
Isolates Ceftazidime/avibactam Ceftolozane/tazobactam
% susceptible
E.coli ESBL 100 93 - 96
K.pneumoniae ESBL 100 42 - 79
KPC + enterobacteriaceae 97 – 100 1 - 4
Merop NS P.aeruginosa 87 78 - 96
XDR P.aeruginosa 67 - 74 46
• Meropenem-vaborbactam• Imipenem-relebactam• Aztreonam-avibactam• Cefiderocol• Plazomicin• Eravacycline
A risk-based algorithm in the choice of empiricantibiotic therapy (EAT) of febrile neutropenia
Febrile neutropenia
Standard risk Escalation: Conventional EAT
High-Risk of XDR-MDR GNB
ESBL colonizationor previousinfection
Escalation: Conventional EAT
+-tigecyclin
De-escalation: NEMS or CEFT-
TZB
Carba-R colonization or
previous infectionDe-escalation
COL-S: COL + other, CAZ-AVI
COL-R: CAZ-AVI + other
COL: colimicin; CAZ-AVI: ceftazidime-avibactam; CEFT-TZB: ceftolozane-tazobactam; NEMS: carbapenems; other: meropenem high dose, tigecycline, aminoglycosides, fosfomycin,
ESBL colonizationRisk of bacteremia :8%
Mortality if bacteremia: 16%:
Carba-R colonizationRisk of bacteremia :28%
Mortality if bacteremia: 60%:
IT-NON-00443-WT-06-2021