Bacteremia due to carbapenem-resistant Enterobacteriaceae in neutropenic patients with hematologic malignancies

Abstract

Objectives To determine the prevalence, risk factors, treatments, and outcomes of bloodstream infections (BSIs) due to carbapenem-resistant Enterobacteriaceae (CRE) in adult neutropenic patients with hematologic malignancies. Methods We reviewed all BSIs between 2008–2012 in this population at two New York City oncology centers. A case-control study was conducted to identify CRE BSI risk factors, using three controls of non-CRE BSIs per case. Results CRE caused 43 (2.2%) of 1,992 BSIs overall and 4.7% of Gram-negative bacteremias. Independent risk factors for CRE BSI were prior β-lactam/β-lactamase inhibitor (adjusted odds ratio [aOR] 3.2; P=0.03) or carbapenem (aOR 3.0; P=0.05) use, current trimethoprim-sulfamethoxazole (aOR 24; P=0.001) or glucocorticoid (aOR 5.4, P=0.004) use, and having a prior CRE culture (aOR 12; P=0.03). Patients with CRE bacteremia had a median of 52 hours from culture collection until receipt of active therapy. They had a 51% BSI-related mortality rate, with a median of 4 days from bacteremia onset until death. CRE-active empirical therapy was associated with a lower 30-day mortality rate (17% vs. 59%; P=0.08). Conclusions CRE are lethal emerging causes of bacteremia in neutropenic patients. New strategies are needed to shorten the delay in administration of CRE-active agents and improve outcomes in this vulnerable population.

Antimicrobial Resistance in Gram-Negative Rods Causing Bacteremia in Hematopoietic Stem Cell Transplant Recipients: Intercontinental Prospective Study of the Infectious Diseases Working Party of the European Bone Marrow Transplantation Group

“…We demonstrated higher mortality rates in infections caused by resistant ba similar to other studies [8,12]. Analysis of mortality risk factors is beyond t of this manuscript.…”

“…Onl handful describe risk factors for carbapenem-resistant infections in popula involving but not limited to transplant patients, mainly for K. pneumoniae. D from other studies, we found that breakthrough on noncarbapenems does n predispose to carbapenem resistance in allo-HSCT patients [8,14]. Noncarb may be explained by increased resistance rates over time [5].…”

Clinical Outcomes Associated with Polymyxin B Dose in Patients with Bloodstream Infections Due to Carbapenem-Resistant Gram-Negative Rods

“…Interestingly, immunosuppression and longer time to active antibiotic therapy were associated with decreased mortality. Two prior studies conducted at our institution evaluated immunocompromised patients with bacteremia due to CRE and found that death often occurred within 3 to 4 days of BSI onset (23,24). This early mortality may have resulted in many of the more severely ill immunocompromised patients being excluded because they did not receive 48 h of polymyxin B.…”

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

“…47,48 Biofilm facilitates MRSA survival and multiplication, prolonging the organism's exposure to antibiotics as well as promoting the transfer of antibiotic resistance genes among strains. 49 53 Multiple antibiotics, steroids and prior CRE colonization were determined to be risk factors for CRE BSI, and delay in receipt of CRE-active therapy was associated with worse outcomes. First described in India, New Delhi metallo-β-lactamase-1 (NDM-1)-producing CRE have since spread globally.…”