title: Post-surgical mediastinitis due to carbapenem-resistant Enterobacteriaceae: Clinical, epidemiological and survival characteristics.
abstract: Invasive infections due to carbapenem-resistant Enterobacteriaceae (CRE), including polymyxin-resistant (PR-CRE) strains, are being increasingly reported. However, there is a lack of clinical data for several life-threatening infections. Here we describe a cohort of patients with post-surgical mediastinitis due to CRE, including PR-CRE. This study was a retrospective cohort design at a single cardiology centre. Patients with mediastinitis due to CRE were identified and were investigated for clinically relevant variables. Infecting isolates were studied using molecular techniques. Patients infected with polymyxin-susceptible CRE (PS-CRE) strains were compared with those infected with PR-CRE strains. In total, 33 patients with CRE mediastinitis were studied, including 15 patients (45%) with PR-CRE. The majority (61%) were previously colonised. All infecting isolates carried blaKPC genes. Baseline characteristics of patients with PR-CRE mediastinitis were comparable with those with PS-CRE mediastinitis. Of the patients studied, 70% received at least one agent considered active in vitro and most patients received at least three concomitant antibiotics. Carbapenem plus polymyxin B was the most common antibiotic combination (73%). Over 90% of patients underwent surgical debridement. Overall, in-hospital mortality was 33% and tended to be higher in patients infected with PR-CRE (17% vs. 53%; P=0.06). In conclusion, mediastinitis due to CRE, including PR-CRE, can become a significant challenge in centres with CRE and a high cardiac surgery volume. Despite complex antibiotic treatments and aggressive surgical procedures, these patients have a high mortality, particularly those infected with PR-CRE.
authors.affiliation: Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil. Electronic address: cely.saad@gmail.com.
authors.forename: C S
authors.initials: CS
authors.lastname: Abboud
authors.affiliation: Associação Fundo de Incentivo à Pesquisa (AFIP-Medicina Diagnóstica), São Paulo, Brazil.
authors.forename: J
authors.initials: J
authors.lastname: Monteiro
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Centro de Educación Médica e Investigaciones Clínicas 'Norberto Quirno' (CEMIC), Buenos Aires, Argentina.
authors.forename: M E
authors.initials: ME
authors.lastname: Stryjewski
authors.affiliation: Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
authors.forename: E C
authors.initials: EC
authors.lastname: Zandonadi
authors.affiliation: Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
authors.forename: V
authors.initials: V
authors.lastname: Barbosa
authors.affiliation: Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
authors.forename: D
authors.initials: D
authors.lastname: Dantas
authors.affiliation: Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil.
authors.forename: E E
authors.initials: EE
authors.lastname: Sousa
authors.affiliation: Laboratório Especial de Microbiologia Clínica (LEMC), Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), São Paulo, Brazil.
authors.forename: M J
authors.initials: MJ
authors.lastname: Fonseca
authors.affiliation: University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.
authors.forename: D M
authors.initials: DM
authors.lastname: Jacobs
authors.affiliation: Laboratório Especial de Microbiologia Clínica (LEMC), Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), São Paulo, Brazil.
authors.forename: A C
authors.initials: AC
authors.lastname: Pignatari
authors.affiliation: Laboratório Especial de Microbiologia Clínica (LEMC), Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), São Paulo, Brazil.
authors.forename: C
authors.initials: C
authors.lastname: Kiffer
authors.affiliation: University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.
authors.forename: G G
authors.initials: GG
authors.lastname: Rao
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D015780:Carbapenems / Q000494:pharmacology*; D004755:Enterobacteriaceae / Q000187:drug effects* / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D008875:Middle Aged; D011113:Polymyxins / Q000494:pharmacology; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D016019:Survival Analysis; D013903:Thoracic Surgery; D018440:beta-Lactam Resistance
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems; D011113:Polymyxins
keywords: Carbapenem-resistant Enterobacteriaceae; Mediastinitis; Polymyxin resistance; Post-surgical infection