title: Epidemiology and Resistance Patterns of Bacterial and Fungal Colonization of Biliary Plastic Stents: A Prospective Cohort Study.
abstract: Plastic stents used for the treatment of biliary obstruction will become occluded over time due to microbial colonization and formation of biofilms. Treatment of stent-associated cholangitis is often not effective because of inappropriate use of antimicrobial agents or antimicrobial resistance. We aimed to assess the current bacterial and fungal etiology of stent-associated biofilms, with particular emphasis on antimicrobial resistance.
  
  
  
  Patients with biliary strictures requiring endoscopic stent placement were prospectively enrolled. After the retrieval of stents, biofilms were disrupted by sonication, microorganisms were cultured, and isolates were identified by matrix-associated laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry and/or biochemical typing. Finally, minimum inhibitory concentrations (MICs) were determined for various antimicrobial agents. Selected stents were further analyzed by fluorescence in situ hybridization (FISH).
  
  
  
  Among 120 patients (62.5% males, median age 64 years) with biliary strictures (35% malignant, 65% benign), 113 double pigtail polyurethane and 100 straight polyethylene stents were analyzed after a median indwelling time of 63 days (range, 1-1274 days). The stent occlusion rate was 11.5% and 13%, respectively, being associated with a significantly increased risk of cholangitis (38.5% vs. 9.1%, P<0.001). Ninety-five different bacterial and 13 fungal species were detected; polymicrobial colonization predominated (95.8% vs. 4.2%, P<0.001). Enterococci (79.3%), Enterobacteriaceae (73.7%), and Candida spp. (55.9%) were the leading pathogens. Candida species were more frequent in patients previously receiving prolonged antibiotic therapy (63% vs. 46.7%, P = 0.023). Vancomycin-resistant enterococci accounted for 13.7%, extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae with co-resistance to ciprofloxacin accounted for 13.9%, and azole-resistant Candida spp. accounted for 32.9% of the respective isolates.
  
  
  
  Enterococci and Candida species play an important role in the microbial colonization of biliary stents. Therefore, empirical antimicrobial treatment of stent-associated cholangitis should be guided toward enterococci, Enterobacteriaceae, streptococci, anaerobes, and Candida. To determine causative pathogens, an accurate microbiological analysis of the extracted stent(s) may be helpful.
authors.affiliation: Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.|Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.|Interdisciplinary Center for Infectious Diseases, Leipzig University Hospital, D-04103 Leipzig, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Lübbert
authors.affiliation: Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Karolin
authors.initials: K
authors.lastname: Wendt
authors.affiliation: Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Feisthammel
authors.affiliation: Biofilm Center, German Heart Institute (Deutsches Herzzentrum Berlin, DHZB), Hindenburgdamm 30, D-12203 Berlin, Germany.
authors.forename: Annette
authors.initials: A
authors.lastname: Moter
authors.affiliation: Interdisciplinary Center for Infectious Diseases, Leipzig University Hospital, D-04103 Leipzig, Germany.|Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Liebigstr. 21, D-04103 Leipzig, Germany.
authors.forename: Norman
authors.initials: N
authors.lastname: Lippmann
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Thilo
authors.initials: T
authors.lastname: Busch
authors.affiliation: Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Mössner
authors.affiliation: Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Albrecht
authors.initials: A
authors.lastname: Hoffmeister
authors.affiliation: Interdisciplinary Center for Infectious Diseases, Leipzig University Hospital, D-04103 Leipzig, Germany.|Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Liebigstr. 21, D-04103 Leipzig, Germany.
authors.forename: Arne C
authors.initials: AC
authors.lastname: Rodloff
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D001419:Bacteria / Q000187:drug effects / Q000254:growth & development* / Q000302:isolation & purification; D001659:Biliary Tract / Q000382:microbiology* / Q000473:pathology*; D018441:Biofilms / Q000187:drug effects / Q000254:growth & development; D001826:Body Fluids; D002648:Child; D015169:Colony Count, Microbial; D004352:Drug Resistance, Microbial / Q000187:drug effects; D004724:Endoscopy; D005260:Female; D005658:Fungi / Q000187:drug effects / Q000254:growth & development* / Q000302:isolation & purification; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011446:Prospective Studies; D016459:Prosthesis-Related Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology*; D013010:Sonication; D015607:Stents / Q000009:adverse effects / Q000382:microbiology*; D013997:Time Factors; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents