Carbapenem-resistant Enterobacteriaceae colonization (CRE) and subsequent risk of infection and 90-day mortality in critically ill patients, an observational study

Abstract

BackgroundCarbapenem-resistant Enterobacteriaceae (CRE) have emerged as an urgent public health threat. Intestinal colonization with CRE has been identified as a risk factor for the development of systemic CRE infection, but has not been compared to colonization with third and/or fourth generation cephalosporin-resistant (Ceph-R) Enterobacteriaceae. Moreover, the risk conferred by colonization on adverse outcomes is less clear, particularly in critically ill patients admitted to the intensive care unit (ICU).MethodsWe carried out a cohort study of consecutive adult patients screened for rectal colonization with CRE or Ceph-R upon ICU entry between April and July 2013. We identified clinical variables and assessed the relationship between CRE or Ceph-R colonization and subsequent systemic CRE infection within 30 days (primary outcome) and all-cause mortality within 90 days (secondary outcome).ResultsAmong 338 ICU patients, 94 (28%) were colonized with either Ceph-R or CRE. 26 patients developed CRE infection within 30 days of swab collection; 47% (N = 17/36) of CRE-colonized and 3% (N = 2/58) of Ceph-R colonized patients. 36% (N = 13/36) of CRE-colonized patients died within 90 days compared to 31% (N = 18/58) of Ceph-R-colonized and 15% (N = 37/244) of non-colonized patients. In a multivariable analysis, CRE colonization independently predicted development of a systemic CRE infection at 30 days (aOR 10.8, 95% CI2.8–41.9, p = 0.0006); Ceph-R colonization did not (aOR 0.5, 95% CI0.1–3.3, p = 0.5). CRE colonization was associated with increased 90-day mortality in a univariable analysis (p-value 0.001), in a multivariable model, previous hospitalization and medical ICU admission were independent predictors of 90-day mortality whereas CRE colonization approached significance (aOR 2.3, 95% CI1.0–5.3, p = 0.056).ConclusionsOur study highlights the increased risk of CRE infection and mortality in patients with CRE colonization at the time of ICU admission. Future studies are needed to assess how CRE colonization can guide empiric antibiotic choices and to develop novel decolonization strategies.

Gastrointestinal Carriage of Vancomycin-Resistant Enterococci and Carbapenem-Resistant Gram-Negative Bacteria in an Endemic Setting: Prevalence, Risk Factors, and Outcomes

“…Similar studies from other regions have reported VRE carriage rates ranging from 2 to 37% (13-15), while prevalence rates for CRGN rectal carriage ranged from 5.3 to 52% (16)(17)(18). At the same time, there is an increased risk of carbapenem-resistant enterobacteriaceae (CRE) infection and mortality in patients who test positive for carriage of CRE (19,20). To the best of our knowledge, there is no previous study from Greece focusing on both VRE and CRGN rectal carriage, exploring respective risk factors and adverse outcomes.…”

“…Little is known, though, about the mechanisms that promote progression from carriage to infection. Increased total LOS among CRE carriers has been previously described (19,49), as well as the association with increased rate of CRE infections and high mortality (19,20). Previous research has demonstrated that CRE infections are associated more often with sepsis and increased early mortality rate (52), particularly in vulnerable patients such as pediatric, geriatric, immunosuppressed, hospitalized, and chronically ill (53,54).…”

The Likelihood of Developing a Carbapenem-Resistant Enterobacteriaceae Infection during a Hospital Stay

“…Although several studies have identified CRE colonization as a risk factor for subsequent CRE infection (6,7), available investigations do not explore whether this risk differs based on the production of carbapenemases by the colonizing strain. This information is important because it can guide whether the additional step of performing phenotypic or genotypic testing on rectal isolates positive for CRE provides added value.…”

Different screening frequencies of carbapenem-resistant Enterobacteriaceae in patients undergoing hematopoietic stem cell transplantation: which one is better?

“…Gut colonization by CRE is an independent risk factor for CRE infection [7,8,11,12]. An Italian multicenter study showed that in patients who underwent autologous and allogeneic HSCT, the CRE colonization rates were 1 and 2.4%, respectively.…”