Infectious disease clinics of North America最新文献

This article emphasizes the global threat of antimicrobial resistance, highlighting its origins, mechanisms, and widespread impact on patient care and public health. It discusses the consequences of suboptimal antibiotic use, including increased infections, resistance, and adverse effects like Clostridioides difficile. The importance of antimicrobial stewardship and infection prevention programs working collaboratively to optimize antibiotic prescribing, reduce unnecessary use, and implement diagnostic stewardship strategies is underscored. Key approaches include shortening therapy durations, transitioning to oral antibiotics, and improving diagnostic accuracy. Coordinated efforts in stewardship and infection control are vital to combating antimicrobial resistance, improving patient outcomes, and safeguarding future antimicrobial efficacy.

Melioidosis is caused by Burkholderia pseudomallei, a Gram-negative environmental saprophyte found in tropical and subtropical regions globally. The aims of treatment for melioidosis are to prevent death and other complications of septic shock, and to eradicate B. pseudomallei and prevent relapse. To achieve these aims, treatment comprises an intensive phase involving minimum 10-14 days of intravenous ceftazidime, meropenem, or imipenem, and a prolonged eradication phase of at least 3 months of oral trimethoprim-sulfamethoxazole. Here, we review the clinical trial and other evidence that supports melioidosis treatment guidelines, and the approach to complications including treatment side effects, relapse, and antimicrobial resistance.

Vancomycin-resistant enterococci (VRE) are major health care-associated pathogens and significantly contribute to patient morbidity and mortality, particularly in immunocompromised and critically ill patients. The clinical management of VRE infections is challenging due to limited therapeutic options and the paucity of high quality clinical data to guide management. Delays in initiating appropriate therapy has proven to have significant impact in VRE-associated bloodstream infections. This review summarizes the current evidence on treatment strategies for serious VRE infections, incluiding bacteremia and endocarditis, as well as emerging treatment strategies for these recalcitrant organisms.

Acinetobacter baumannii, particularly carbapenem-resistant strains (CRAB), represents a critical global health threat due to its multidrug resistance and association with severe healthcare-associated infections. Treatment options remain limited, with high mortality rates observed in ventilator-associated pneumonia (VAP), bloodstream infections (BSI), and central nervous system (CNS) infections. Colistin-based regimens, despite toxicity and pharmacokinetic limitations, have long been standard therapy. Recent therapeutic advances include cefiderocol and sulbactam/durlobactam, which show potential activity, especially when used in combination regimens.

Solid organ transplant recipients (SOTr) are at increased risk of both becoming colonized and infected with multidrug-resistant organisms (MDROs) owing to diverse host, environment and exposure factors. Despite significant advances in surgical techniques, management of immunosuppression, and the application of antimicrobial prophylaxis and infection control practices, the burden of these infections remains high and is associated with increased morbidity, mortality, and adverse graft outcomes. The present review aims to highlight the current state of epidemiology, risk factors, antibiotic and nonantibiotic therapeutics, and infection control and antibiotic stewardship strategies in the management of severe bacterial infections caused by MDROs in SOTr.

Extended-spectrum β-lactamase (ESBL)-producing bacteria are increasingly common, especially in community settings of low-resource areas. While intravenous carbapenems are the most effective treatment, rising resistance highlights the importance of limiting their use. Alternative options, including certain penicillins, cephamycins, aminoglycosides, and fluoroquinolones, show promise and are being reconsidered due to availability and cost. Oral therapies like oral carbapenems and trimethoprim-sulfamethoxazole may enable earlier discharge and outpatient care. Newer β-lactams are in development but may be limited by high costs. Overall, combining intravenous and oral noncarbapenem agents with carbapenems used selectively can optimize ESBL infection management.

Carbapenem-resistant enterobacterales (CRE) remain a major clinical and public health concern, with limited treatment options. Given the heterogeneity in resistance mechanisms, infection syndromes, and host factors, selecting optimal therapy requires an individualized approach. A review of treatment guidelines, clinical studies, and in vitro data supports the use of ceftazidime-avibactam for KPC- and OXA-48-like carbapenemase producers, and ceftazidime-avibactam with aztreonam (or aztreonam-avibactam) for metallo-β-lactamases. For carbapenemase-producing CRE, cefiderocol may also be considered if susceptibility is confirmed. Where possible, colistin and polymyxin B should be avoided due to toxicity and lack of robust clinical data.

Hypervirulent Klebsiella pneumoniae (HvKp) is a highly invasive pathotype causing severe, community-acquired infections, unlike nosocomial classic K pneumoniae. First reported in 1986, HvKp is linked to liver abscess, bacteremia, and endophthalmitis, driven by K1/K2 polysaccharide capsule, hypermucoviscous capsule production and siderophores. It colonizes the gut, with high prevalence in the Asia-Pacific, but is emerging globally, including in Europe and the United States. The convergence of hypervirulence and multidrug resistance, notably carbapenem resistance, limits treatment options, prompting a World Health Organization alert in 2024. Management includes source control (percutaneous drainage) and antibiotics. Evidence-based treatment strategies are urgently needed.

AmpC β-lactamases, found in certain Enterobacterales, confer resistance to third-generation cephalosporins, some β-lactam/β-lactamase inhibitor combinations, and cephamycins. They may be chromosomal or plasmid-mediated. Generally, third-generation cephalosporins are avoided in the treatment of high-risk AmpC producers, with cefepime or carbapenems being preferred for severe infections. Non-β-lactam options (fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides) remain viable options if they test susceptible. New β-lactam/β-lactamase inhibitors and cefiderocol retain activity against AmpC, but are generally reserved for situations where AmpC coexists with carbapenemases. Optimal therapy remains unclear and should be informed by well-designed prospective studies or randomized controlled trials.

Novel technologies for the diagnosis of bloodstream infection are emerging, with the potential to improve patient care. Antimicrobial stewardship programs have proven essential to embed such tests into clinical practice and thus support early appropriate antimicrobial therapy. Yet, the best implementation strategies for these tests are still unknown and likely dependent on the specific scenarios, including local epidemiology, patient characteristics, and laboratory resources. Moreover, evidence about the impact of such tests on clinical outcomes and their cost-effectiveness is still limited. These uncertainties challenge the commercial sustainability of these tests and randomized controlled trials are advocated to prove their benefit.