Carbapenem-resistant Klebsiella pneumoniae in high-risk haematological patients: factors favouring spread, risk factors and outcome of carbapenem-resistant Klebsiella pneumoniae bacteremias

Abstract

BackgroundCarbapenem-resistant Klebsiella pneumoniae (CRKP) spread and infections in patients with haematological malignancies are a serious concern especially in endemic areas. Treatment failures and delay in appropriate therapy for CRKP infections are frequent and the mortality rate associated with CRKP bacteremia in neutropenic haematological patients is reported about 60%.MethodsHaematological patients harboring CRKP hospitalized between February 2012 and May 2013 in an Italian Teaching hospital were examined. Conditions favouring CRKP spread in a haematological unit, risk factors for bacteremia in CRKP-carriers and for CRKP bacteremia-related death were evaluated in this observational retrospective study.ResultsCRKP was isolated in 22 patients, 14 (64%) had bacteremia. Control measures implementation, particularly the weekly rectal screening for CRKP performed in all hospitalized patients and contact precautions for CRKP-carriers and newly admitted patients until proved CRKP-negative, reduced significantly the CRKP spread (14 new carriers identified of 131 screened patients vs 5 of 242 after the intervention, p = 0.001). Fifty-eight percent of carriers developed CRKP bacteremia, and acute myeloid leukemia (AML) resulted independently associated with the bacteremia occurrence (p = 0.02). CRKP bacteremias developed mainly during neutropenia (86%) and in CRKP-carriers (79%). CRKP bacteremias were breakthrough in 10 cases (71%). Ten of 14 patient with CRKP bacteremias died (71%) and all had AML. The 70% of fatal bacteremias occurred in patients not yet recognized as CRKP-carriers and 80% were breakthrough. Initial adequate antibiotic therapy resulted the only independent factor able to protect against death (p = 0.02).ConclusionsThe identification of CRKP-carriers is confirmed critical to prevent CRKP spread. AML patients colonized by CRKP resulted at high risk of CRKP-bacteremia and poor outcome and the adequacy of the initial antibiotic therapy may be effective to improve survival. To limit the increase of resistance, the extensive use of antibiotics active against CRKP should be avoided, but in the setting of high CRKP pressure and high-risk CRKP-colonized haematological patients, timely empiric antibiotic combinations active against CRKP could be suggested as treatment of febrile neutropenia.

Bacterial profile and antibiogram of blood stream infections in febrile neutropenic patients with haematological malignancies

“…However, in the present study K. pneumoniae was the most frequently isolated bacteria followed by Enterobacter sp (20%), Escherichia coli (12%) and Pseudomonas aeruginosa (12%). The rise of K. pneumoniae, especially drug resistant isolates, has been documented by Satlin et al and Micozzi et al in recent studies [11,12].…”

“…The alarming development of resistance to beta lactam beta lactamase inhibitor combinations and carbapenems in the present study is a direct result of increase in the prevalence of resistant Enterobacteriaceae like K. pneumoniae and Enterobacter sp. Worldwide, several reports have appeared on the emergence of carbapenem resistant Enterobacteriaceae especially K. pneumoniae causing infection in cancer patients [4,11,12].Carbapenem resistant K. pneumoniae and Enterobacter have even caused outbreaks leading to BSI and death in cancer patients [16]. Patients with haematological malignancies are particularly vulnerable to these infections because of the above-mentioned risk factors [10].…”

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

“…The other subsequently developed a CRE BSI but survived due to timely combination with polymyxin (changed later to ceftazidime-avibactam because of the nephrotoxicity). These results also highlight that for CRE colonized patients with febrile neutropenia and clinical signs of infection, prompt and active targeted CRE treatment contribute to improvement of prognosis [4,31]. For patients colonized with CRE without fever, contact precaution is necessary, while the administration of antibiotics should be cautious and avoid abuse.…”

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

“…These results also highlight that for CRE colonized patients with febrile neutropenia and clinical signs of infection, prompt and active targeted CRE treatment contribute to improvement of prognosis. [4,33] For patients colonized with CRE without fever, contact precaution is necessary, while the administration of antibiotics should be cautious and avoid abuse. In our study, patients colonized with CRE in the absence of febrile episodes were only isolated and observed, did not receive tigecycline treatment and got favorable prognosis.…”