Issam Raad

University of Texas MD Anderson Cancer Center, Houston, Texas, United States

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Publications (437)1849.76 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Different types of central venous catheters (CVCs) have been used in clinical practice to improve the quality of life of chronically and critically ill patients. Unfortunately, indwelling devices are usually associated with microbial biofilms and eventually lead to catheter-related bloodstream infections (CLABSIs).An estimated 250,000-400,000 CLABSIs occur every year in the United States, at a rate of 1.5 per 1,000 CVC days and a mortality rate of 12-25 %. The annual cost of caring for patients with CLABSIs ranges from 296 million to 2.3 billion dollars.Biofilm formation occurs on biotic and abiotic surfaces in the clinical setting. Extensive studies have been conducted to understand biofilm formation, including different biofilm developmental stages, biofilm matrix compositions, quorum-sensing regulated biofilm formation, biofilm dispersal (and its clinical implications), and multi-species biofilms that are relevant to polymicrobial infections.When microbes form a matured biofilm within human hosts through medical devices such as CVCs, the infection becomes resistant to antibiotic treatment and can develop into a chronic condition. For that reason, many techniques have been used to prevent the formation of biofilm by targeting different stages of biofilm maturation. Other methods have been used to diagnose and treat established cases of CLABSI.Catheter removal is the conventional management of catheter associated bacteremia; however, the procedure itself carries a relatively high risk of mechanical complications. Salvaging the catheter can help to minimize these complications.In this article, we provide an overview of microbial biofilm formation; describe the involvement of various genetic determinants, adhesion proteins, organelles, mechanism(s) of biofilm formation, polymicrobial infections, and biofilm-associated infections on indwelling intravascular catheters; and describe the diagnosis, management, and prevention of catheter-related bloodstream infections.
    Advances in experimental medicine and biology 01/2015; 830:157-79. · 1.83 Impact Factor
  • Issam Raad, Anne-Marie Chaftari
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    ABSTRACT: Central lines, which are essential for treating cancer, are associated with at least 400 000 episodes of bloodstream infection in patients with cancer every year in the United States. Effective novel interventions for preventing and managing these infections include antimicrobial-coated catheters and antimicrobial lock solutions.
    Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 11/2014; 59 Suppl 5:S340-3.
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    ABSTRACT: Invasive aspergillosis (IA) is a life-threatening infection in severely immunocompromised haematological malignancy patients. In this study, the efficacy and safety of caspofungin, voriconazole or the combination as primary and salvage therapy in patients with IA were compared. The study included 181 patients with haematological malignancies and IA who received primary or salvage therapy with caspofungin, voriconazole or the combination. In total, 138 patients who received treatment for ≥7 days were analysed; 86 underwent primary antifungal therapy (15 with caspofungin, 38 with voriconazole and 33 with both). Among the salvage therapy patients, 17 received caspofungin, 24 received voriconazole and 35 received both. In the primary therapy group, no difference in therapy response was found, but caspofungin was associated with higher IA mortality rates. A multivariate competing risk analysis of primary antifungal therapy revealed that voriconazole was independently associated with lower IA-associated mortality rates than caspofungin (hazard ratio = 0.2, 95% confidence interval 0.06–0.96; P = 0.04). In the salvage therapy group, the three treatment groups had similar responses and IA-associated mortality rates. The combination of voriconazole and caspofungin did not result in better outcomes compared with voriconazole alone, as primary or salvage therapy, in haematological malignancy patients. However, voriconazole was associated with a lower Aspergillus-associated mortality rate compared with caspofungin monotherapy.
    International Journal of Antimicrobial Agents. 10/2014;
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    ABSTRACT: Background: Procalcitonin (PCT) and Interleukin-6 (IL-6) have emerged as biomarkers for different inflammatory conditions, including cancer and infection. The purpose of the study was to evaluate the role of PCT and IL-6 as biomarkers of cancer and its progression in a large cohort of patients with and without infection. Methods: This prospective, observational study included residual plasma samples collected from febrile and non-febrile cancer patients, and control subjects without cancer. Levels of PCT and IL-6 were determined by Kryptor compact bioanalyzer and ELISA respectively. Results: We identified a total of 1064 patients, including 575 febrile cancer patients, 410 non-febrile cancer patients, and 79 non-cancer individuals. The median PCT level was lower in control subjects (0.029 ng/ml) compared to cancer patients with stage I-III disease (0.127 ng/ml) (p<0.0001) and stage IV disease (0.190 ng/ml) (p<0.0001). It was also higher in febrile cancer patients (0.310 ng/ml) compared to non-febrile cancer patients (0.1 ng/ml) (p<0.0001). PCT was also higher in febrile cancer patients with sepsis or bacteremia (0.490 ng/ml) compared to those without microbiological documented infection (0.310 ng/ml) (p=0.003). Median IL-6 level was significantly lower in the control group (0 pg/ml) than in non-febrile cancer patients with stages I-III (7.376 pg/ml) or stage IV (9.635 pg/ml) (p<0.0001), but did not differ in patients with stage IV cancer from those with stage I-III. Conclusion: Our results suggest a potential role for PCT and IL-6 in predicting cancer in non-febrile patients. PCT is also useful in detecting cancer and its progression in non-febrile patients. However, in febrile cancer patients, PCT predicts bacteremia or sepsis.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Isavuconazole (ISA) is a novel broad-spectrum triazole antifungal available as a water-soluble prodrug in IV and oral formulations for treatment of invasive fungal disease. A Phase 3 trial assessed the efficacy and safety of ISA vs. voriconazole (VRC) in patients with IMD. Here we report outcomes in a pre-specified subset of patients from this non-inferiority trial, who had proven, probable, or possible pulmonary mold disease (PMD) without other site involvement (lower respiratory tract disease only). Methods: Patients were randomized 1:1 to receive ISA or VRC for up to 84 days. Dosing regimens were: ISA 200mg IV TID for 2 days, followed by 200mg QD (IV or PO); VRC 6mg/kg IV BID on Day 1, 4mg/kg IV BID on Day 2, then either 4mg/kg IV BID or 200mg PO BID. Eligibility criteria and pre-specified outcomes are available at clinicaltrials.gov, NCT00412893. The primary efficacy endpoint was all-cause mortality by Day 42. All-cause mortality on Day 84, overall success (complete + partial response) at end of treatment (EOT) determined by an independent blinded data review committee were recorded. Safety and tolerability were also assessed, as reported by the Investigator. Results: Overall 412 patients with proven/probable/possible PMD, primarily caused by Aspergillus spp. (n=224), were enrolled. Patient characteristics, outcomes, and adverse events (AEs) are presented in Table 1. Outcomes in patients with proven/probable cases were similar to those with proven/probable/possible infections. Table 1.Efficacy and safety in patients with PMD Parameter ISA (n=200) VRC (n=212) Adjusted difference* % (95% CI) All-cause mortality on Day 42 34 (17) 44 (21) −2.9 (−10.4, 4.6) All-cause mortality on Day 84 55 (28) 68 (32) −3.8 (−12.4, 4.8) Overall success at EOT 82 (41) 89 (42) −1.8 (−11.1, 7.4) Complete response 28 (14) 35 (17) Partial response 54 (27) 54 (25) Stable 53 (27) 60 (28) Progression 65 (33) 63 (30) Safety P value AEs 194 (97) 210 (99) 0.2 Study drug-related AEs 85 (43) 130 (61) <0.001 Serious AEs 108 (54) 128 (60) 0.2 Study drug-related serious AEs 24 (12) 27 (13) 0.9 AE leading to permanent discontinuation 33 (17) 53 (25) 0.04 *(ISA–VRC) Conclusion: ISA had comparable efficacy to VRC for the primary treatment of PMD patients, but had a lower rate of drug-related AEs vs. VRC
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Isavuconazole (ISA) is a novel, water-soluble, broad-spectrum triazole antifungal available in IV and oral formulations for treatment of invasive fungal disease. A Phase 3 trial (NCT00412893) assessed the efficacy and safety of ISA vs. voriconazole (VRC) in patients with invasive mold disease (IMD). Here we report on a pre-specified subset of patients from this trial who had proven/probable invasive aspergillosis (IA) (EORTC/MSG criteria) and received ≥1 dose of the study drug. Methods: Patients were randomized 1:1 to receive ISA or VRC for up to 84 days. Dosing regimens were: ISA 200mg IV TID for 2 days, followed by 200mg QD (IV or PO); VRC 6mg/kg IV BID on Day 1, 4mg/kg IV BID on Day 2, then either 4mg/kg IV BID or 200mg PO BID. The primary efficacy endpoint was all-cause mortality (ACM) through Day 42. Overall success at end of treatment (EOT) and safety were also assessed. All diagnoses and outcomes were assessed by an independent, blinded, data-review committee. Safety data are presented as reported by the Investigator. Results: Overall 231 patients were included in this analysis (ISA n=123; VRC n=108). Patient characteristics, efficacy, and safety outcomes are shown in Table 1. Differences in drug-related AEs between ISA and VRC were statistically significant (p<0.001). Table 1.Patient characteristics and outcomes ISA (n=123) VRC (n=108) Patient characteristics Age (years), mean ± SD 51 ± 16 52 ± 15 Male, n (%) 69 (56) 71 (66) Primary underlying condition, n (%) Acute myeloid leukemia Acute lymphocytic leukemia Non-Hodgkin’s lymphoma Other 44 (36) 15 (12) 14 (11) 49 (40) 47 (44) 9 (8) 2 (2) 49 (45) Outcome – Efficacy ACM on Day 42, n (%) 23 (19) 24 (22) Adjusted difference (ISA–VRC), % (95% CI) −2.7 (−12.9, 7.5) ACM on Day 84 35 (29) 39 (36) Adjusted difference (ISA–VRC), % (95% CI) −5.7 (−17.1, 5.6) Overall success at EOT, n (%) 43 (35) 42 (39) Adjusted difference (VRC–ISA), % (95% CI) 4.0 (−8.0, 15.9) Outcome – Safety, n (%) AEs 118 (96) 106 (98) Drug-related AEs 48 (39) 67 (62) Serious AEs 71 (58) 71 (66) Drug-related serious AEs 16 (13) 13 (12) AEs leading to discontinuation 22 (18) 26 (24) Conclusion: In patients with documented IA, ISA had comparable efficacy to VRC, but was better tolerated than the latter.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Gram-positive bacteria are a leading cause of blood stream infections (BSI) in cancer patients. Televancin is a bactericidal glycopeptide which has not been compared to vancomycin in cancer patients with BSI. We therefore compared the clinical efficacy and safety of telavancin to vancomycin in cancer patients with gram-positive BSI. Methods: Between March 2011 and May 2013, we enrolled 40 cancer patients (39 evaluable) with uncomplicated Gram-positive BSI who received intravenous telavancin for at least 14 days for S. aureus and 7 days for other Gram-positive cocci. Patients with baseline creatinine clearance (Cr Cl) > 50 ml/min received a daily dose of 10mg/kg and those with Cr Cl between 30-49 ml/min received a dose of 7.5 mg/kg. Patients were followed for 1 month after the last dose of study drug. These patients were compared with 39 historical matched control patients (based on underlying disease, type of organism and neutropenia) who were treated with vancomycin. Results: A total of 78 evaluable patients were analyzed, 39 patients in each group. The most common pathogens causing BSI were Staphylococcus aureus (n = 20), followed by alpha-hemolytic Streptococci (n=7), Enterococcus (n=7), coagulase-negative Staphylococcus (n=4), and beta-hemolytic Streptococci (n=1). 62% of patients had hematological malignancies and 51% were neutropenic at onset of bacteremia. There was a possible trend towards a better clinical response associated with telavancin compared with vancomycin (89% vs. 72%; p=0.09). Microbiological response was similar in both groups (telavancin 92% vs vancomycin 95%; p=0.67). Overall mortality and infectious-related mortality were comparable in both arms. Drug related averse events were similar in both groups (telavancin 26% vs. vancomycin 21%; p=0.59). Median creatinine levels and creatinine clearance at baseline, end-of-treatment and last follow-up visits were comparable in both groups. Conclusion: Treatment with telavancin for gram-positive BSI in cancer patients was generally effective and safe and may provide a useful and convenient alternative to standard vancomycin therapy.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Viridans group streptococci (VGS), a leading cause of bloodstream infection (BSI) in cancer patients, are thought to arise from the gastrointestinal tract. We sought to determine whether central venous catheters may serve as the source of VGS BSI, and to compare the ability of the newly proposed mucosal barrier injury laboratory-confirmed BSI definition to assign a VGS BSI source compared with the catheter-related BSI definition.
    American journal of infection control. 10/2014; 42(10):1127-9.
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    ABSTRACT: Central venous catheters (CVC) removal and reinsertion of a new CVC in the setting of central line associated bloodstream infections (CLABSI) is not always possible in septic patients. The purpose of this study was to evaluate the outcome of patients with Staphylococcus aureus-CLABSI (SA-CLABSI) who had their CVCs exchanged over guidewire for minocycline/ rifampin-coated (M/R)-CVC within seven days of bacteremia.
    BMC Infectious Diseases 09/2014; 14(1):518. · 3.03 Impact Factor
  • Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 09/2014;
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    ABSTRACT: Infections in critically ill patients continue to impose diagnostic and therapeutic challenges. We seek to investigate the utility of proadrenomedullin and procalcitonin as diagnostic and prognostic biomarkers in febrile critically ill patients with cancer and compare their performance with that of C-reactive protein.
    Critical care medicine. 07/2014;
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    ABSTRACT: Invasive aspergillosis (IA) caused by Aspergillus terreus is a significant cause of morbidity and mortality in patients with haematological malignancy (HM). Very few data are available in this patient population to differentiate IA patients with A. terreus from those with non-terreus species of Aspergillus to compare outcomes. We retrospectively investigated 513 HM patients who were treated for either definite or probable IA between June 1993 and August 2012 in a cancer centre.
    Journal of Antimicrobial Chemotherapy 07/2014; · 5.34 Impact Factor
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    ABSTRACT: Exchanging central venous catheters (CVCs) over a guidewire for fresh uncoated CVCs in the presence of bacteremia can result in cross-infection of the newly exchanged CVCs. A recent retrospective clinical study showed that exchanging the catheter over a guidewire in the presence of bacteremia using on antimicrobial Minocycline/Rifampin (MR) catheter may improve outcomes. To expand on this, we developed an in vitro cross-contamination model of exchange to evaluate the efficacy of different antimicrobial CVCs in preventing cross-contamination of multi-drug resistant organisms during exchange. Uncoated CVCs were allowed to form biofilm by Methicillin-resistant Staphylococcus aureus (MRSA), STAPHYLOCOCCUS EPIDERMIDIS, ESCHERICHIA COLI: , Pseudomonas aeruginosa, and Candida albicans. After 24h, the biofilm colonized CVCs were placed in a glass-tube containing bovine calf serum plus Muller-Hinton broth, and the catheters were exchanged over guidewire for fresh uncoated, M/R, chlorhexidine-silver/sulfadiazine (CHX/SS), and chlorhexidine-M/R (CHX-M/R) CVCs. Cross-contamination of exchanged catheters was enumerated by sonication and quantitative plating methods. Exchange of M/R CVCs completely prevented cross-contamination by MRSA biofilms compared to control exchanged CVCs (P < 0.0001). CHX/SS reduced but not completely prevent cross-contamination by MRSA (P = 0.005). Exchange with CHX-M/R CVCs completely prevented cross-contamination by MRSA, P. aeruginosa and C. albicans biofilms (P < 0.0001). Furthermore, CHX-M/R was superior to M/R for P. aeruginosa and C. albicans (P = 0.003). CHX-M/R was superior to CHX/SS for MRSA and P. aeruginosa (P = 0.01). In conclusion, exchange with the novel CHX-M/R CVC was the only CVC effective in completely and concurrently preventing cross-contamination of bacteria and Candida.
    Antimicrobial Agents and Chemotherapy 06/2014; · 4.57 Impact Factor
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    ABSTRACT: Background. There are limited data regarding clinical presentation and management of Staphylococcus aureus central line- associated bloodstream infection (CLABSI) in immunocompromised cancer patients. Methods. In this review, we evaluated 299 patients with 304 episodes of S. aureus-CLABSI between 2005 and 2011. Findings. By multivariate analysis, the major predictors of complicated S. aureus-CLABSI were septic shock, catheter site inflammation, presence of peripherally inserted central catheter, anti-cancer chemotherapy within 10 days, and persistent bacteremia beyond 72 hours (P ≤ 0.02). A total of 67% of the cases were defined as complicated. In the subset of patients who were uncomplicated on presentation, patients receiving antimicrobials ≥ 14 days had similar rates of relapse, attributable mortality, and development of complications compared to those receiving shorter-course therapy. By competing risk analysis, removal of the catheter within 3 days of the onset of bacteremia was associated with a lower relapse rate at 90 days (P = 0.024). Interpretation. The majority of S. aureus-CLABSI in cancer patients are complicated and require prolonged course of antimicrobial treatment. Early removal of the catheter within the first 3 days is associated with better course. In patients with prompt removal of the catheter and no evidence of a complicated course, treatment beyond 2 weeks may not be necessary.
    Annals of Medicine 02/2014; · 4.73 Impact Factor
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    ABSTRACT: Considerable progress has been made to understand the association between lifestyle and diet in cancer initiation and promotion. Because excessive glucose consumption is a key metabolic hallmark of cancer cells, glucose restriction (GR) decreases the proliferation, and promotes the differentiation and transformation of cancer cells to quiescent cells. The immortality of cancerous cells is largely assured by telomerase, which is an interesting target for inhibition by BIBR 1532. In this study, we investigated the effect of GR on telomerase activity and on the efficacy of its inhibition by BIBR 1532.
    Cancer Cell International 01/2014; 14:60. · 2.09 Impact Factor
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    ABSTRACT: Objective. The rate of postmastectomy tissue expander (TE) infection remains excessively high, ranging between 2% and 24%. We hypothesized that current perioperative antimicrobial regimens utilized for breast TE reconstruction may be outdated as a result of recent changes in microflora and susceptibility patterns. Design and methods. We reviewed the records of all patients who had a TE reconstructive procedure and developed a definite breast TE infection between 2003 and 2010 at MD Anderson Cancer Center. Antimicrobials were stratified into 3 groups: systemic perioperative, local irrigation, and oral immediate postoperative antimicrobials. These were considered discordant if they did not target the isolated organisms, while a breakthrough infection was defined as an infection that occurred despite concordant antimicrobial coverage. Results. Overall, 75 patients with a definite TE infection were identified. The most common organisms identified were methicillin-resistant Staphylococcus epidermidis (29%), methicillin-resistant Staphylococcus aureus (15%), and gram-negative rods (26%). The use of systemic perioperative antimicrobials was deemed discordant in 51% of the cases. Although 79% of the patients received broad-spectrum perioperative local antimicrobial irrigation, 63% developed a breakthrough infection. Even though 61% received oral postoperative prophylactic antimicrobials, 63% of the times they were deemed discordant. Conclusions. Contrary to the proven effectiveness of a single dose of perioperative antibiotics, the common use of local antimicrobial irrigation and prolonged postoperative oral antibiotics appears to be an inadequate component of our preventive armamentarium. Also, because methicillin-resistant staphylococcal and pseudomonal infections occurred approximately 60% of the time, at institutions that have observed an increase of these organisms, it may be prudent that perioperative antimicrobials target these microorganisms.
    Infection Control and Hospital Epidemiology 01/2014; 35(1):75-81. · 4.02 Impact Factor
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    ABSTRACT: Background Transmission of organisms by contact of gloves with surfaces following contact with a pathogen source has been recognized as an important vector for pathogenesis of health care-associated infections. In these cases, the gloves protect the wearer from contact with the pathogenic organisms; however, this personal protection can facilitate the wearer unwittingly becoming a carrier of the pathogens from one location to another. A novel gendine (combination of chlorhexidine and gentian violet) antiseptic coating for the external surface of the glove was developed as a potential intervention to prevent this mode of transmission. Methods We characterized the ability of the coating to rapidly kill bacterial and fungal pathogens within 1 minute of contact with the glove surface. The International Organization of Standardization 22196 concentrated inoculum contact testing methodology was followed. Results The gendine-coated gloves were able to fully eradicate multidrug-resistant organisms included methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterocci, multidrug-resistant Pseudomonas aeruginosa, and Klebsiella pneumoniae carbapenemase producing. In addition, Candida albicans, Candida glabarata, and 2 pathogenic Escherichia coli strains commonly associated with invasive gastroenteritis were also fully eradicated within 1 minute of contact. The gendine coating did not adversely impact the finish or integrity of the disposable gloves. Conclusion The highly efficacious gendine-coated antimicrobial gloves potentially provide an additional means of protection against horizontal transmission of common pathogens in a hospital setting.
    American journal of infection control 01/2014; 42(1):55–59. · 3.01 Impact Factor
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    ABSTRACT: We developed an in vitro model to evaluate the effect of different cuffed endotracheal tubes (ETTs) on transtracheal transmission of ventilator-associated pneumonia (VAP) pathogens along external surfaces of ETTs. The model independently assessed the relative contributions of microbial proliferation to the distal tip and microaspiration of contaminated secretions past the cuff by testing in three modes: microaspiration only, microbial proliferation only, and simultaneous microaspiration and microbial proliferation. We evaluated transmission of methicillin resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PA) in the presence of a standard ETT; a soft, tapered cuff ETT with subglottic suctioning; and a novel antimicrobial gendine (combination of gentian violet and chlorhexidine) ETT in the model. In the microaspiration only mode, when leakage past the cuff occurred quickly, no ETT prevented transmission. When microaspiration was delayed, the gendine ETT was able to completely disinfect the fluid above the cuff and thereby prevent transmission of pathogens. In microbial proliferation only mode, the gendine ETT was the sole ETT that prevented transmission. With both mechanisms simultaneously available, transmission was dependent on how long microaspiration was delayed. Potent antimicrobial ETTs, such as a gendine ETT, can make unique contributions to prevent VAP when microaspiration is gradual.
    BioMed research international. 01/2014; 2014:120468.
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    ABSTRACT: As infection is a severe complication of Ommaya reservoirs (OR), and existing data is limited, herein we describe the largest study of the clinical manifestations and treatment outcomes of Ommaya reservoir-related infections (ORRI). We retrospectively reviewed the records of all patients at our institution who had an OR placed, and developed a definite device-related infection between 2001-2011. Among 501 OR placements, 40 patients (8%) developed an ORRI. These presented with meningitis and/or meningoencephalitis (60%), cellulitis (20%), or a combination thereof (20%). Approximately 40% occurred ≤30 days of OR placement, while 60% occurred ≤10 days after the device was last accessed. Only 20% presented with leukocytosis, while another 18% had a normal cerebrospinal fluid (CSF). Gram-positive skin flora accounted >80% of the pathogens. The median hospital stay and duration of antibiotics were 13 and 24 days, respectively. Although mortality rates (≈10%) were similar among all treatment groups (p>.99), shorter hospitalization and antimicrobial treatment durations were obtained with early versus late device removal (p<.038). As clinical symptoms can be non-specific and CSF parameters may be within normal limits, a high suspicion for infection is required. The shortest hospitalization and treatment course was achieved with early device removal.
    The Journal of infection 12/2013; · 4.13 Impact Factor
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    ABSTRACT: Resistant gram-negative bacteria are increasing central line associated blood stream infection threats. To better combat this, chlorhexidine (CHX) was added to Minocycline-Rifampin (M/R) catheters. Antimicrobial activity of the CHX-M/R catheters was tested in vitro against multi-drug resistant, gram-negative Acinetobacter baumannii, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Stenotrophomonas maltophilia. M/R and chlorohexidine-silver sulfadiazine catheters (CHX/SS) were used as comparators. The novel CHX-M/R was significantly more effective (P < 0.0001) than CHX/SS or M/R in preventing biofilm colonization and in antimicrobial durability.
    Antimicrobial Agents and Chemotherapy 10/2013; · 4.57 Impact Factor

Publication Stats

15k Citations
1,849.76 Total Impact Points

Institutions

  • 1991–2014
    • University of Texas MD Anderson Cancer Center
      • • Department of Leukemia
      • • Department of Medical Specialities
      • • Department of Internal Medicine Specialties
      • • Department of Head and Neck Surgery
      Houston, Texas, United States
  • 2012
    • Tel Aviv Sourasky Medical Center
      • Infectious Diseases
      Tell Afif, Tel Aviv, Israel
    • Ohio University
      • Department of Chemical and Biomolecular Engineering
      Athens, OH, United States
    • University of Texas at Tyler
      Tyler, Texas, United States
  • 2005–2012
    • University of Texas Health Science Center at Houston
      • Center for Infectious Diseases
      Houston, Texas, United States
    • Shizuoka Cancer Center
      Sizuoka, Shizuoka, Japan
  • 2011
    • Xenex Healthcare Services
      San Antonio, Texas, United States
    • University of Houston
      Houston, Texas, United States
  • 2002–2011
    • National Institutes of Health
      • • Critical Care Medicine Department
      • • Center for Clinical Research
      Bethesda, MD, United States
  • 2009
    • Hebrew University of Jerusalem
      • Department of Pediatrics
      Jerusalem, Jerusalem District, Israel
    • University of Texas Medical School
      Houston, Texas, United States
    • University of South Carolina
      • College of Pharmacy
      Columbia, SC, United States
  • 2007
    • Staten Island University Hospital
      New York, United States
  • 2006
    • Johannes Gutenberg-Universität Mainz
      Mayence, Rheinland-Pfalz, Germany
    • University of Crete
      • School of Medicine
      Retimo, Crete, Greece
  • 2005–2006
    • Wake Forest School of Medicine
      • • Section on Infectious Diseases
      • • Department of Internal Medicine
      Winston-Salem, NC, United States
  • 2001–2005
    • Houston Zoo
      Houston, Texas, United States
  • 1997–2005
    • Baylor College of Medicine
      • • Veterans Affairs Medical Center
      • • Department of Physical Medicine & Rehabilitation
      • • Department of Medicine
      Houston, Texas, United States
  • 2003
    • Beirut University
      Beyrouth, Beyrouth, Lebanon
    • Montana State University
      • Center for Biofilm Engineering
      Bozeman, Montana, United States
  • 1999
    • Tulane University
      • Department of Surgery
      New Orleans, LA, United States
  • 1988–1992
    • University of Florida
      • • Division of Infectious Diseases
      • • Department of Medicine
      Gainesville, FL, United States