Development of a Nomogram for Carbapenem-Resistant Enterobacteriaceae Acquisition Risk Prediction Among Patients in the Intensive Care Unit of a Secondary Referral Hospital

Abstract

This study aimed to identify the risk factors of carbapenem-resistant Enterobacteriaceae (CRE) acquisition to build a nomogram for CRE acquisition risk prediction and evaluate its performance. Methods: This unmatched case-control study included 352 adult patients (55 patients and 297 controls) admitted to the intensive care unit (ICU) of a 453-bed secondary referral hospital between January 1, 2018, and September 31, 2019, in Busan, South Korea. The nomogram was built with the identified risk factors using multiple logistic regression analysis. Its performance was analyzed using calibration-in-thelarge, the slope of the calibration plot, concordance statistic (c-statistic), and the sensitivity and specificity of the training set, subsets, and a new test set. Results: The risk factors of CRE acquisition among ICU patients at a secondary referral hospital were Acute Physiology and Chronic Health Evaluation II score at the time of admission, use of a central venous catheter and a nasogastric tube, as well as use of cephalosporin antibiotics. At 20.0% of the predicted CRE acquisition risk in the training set, the calibration-in-the-large was 0, slope of the calibration plot was 1, c-statistic was .93, sensitivity was 85.5%, and specificity was 84.8%. The performance was relatively good in the subsets and new test set. Conclusion:The nomogram can be used to monitor the CRE acquisition risk for ICU patients who have a similar case mix to patients in the study hospitals. Future studies need to involve more rigorous methodology and larger samples.

A Nomogram With Six Variables Is Useful to Predict the Risk of Acquiring Carbapenem-Resistant Microorganism Infection in ICU Patients

“…Public health workers can use this nomogram to easily assess the risk of acquiring CRO infection among ICU patients and to decide on the development of concrete prevention and control strategies. In this study, approximately 4.04% of patients with first ICU admission had CRO infection, a proportion that was lower than that reported in other studies (Li et al, 2019;Giannella et al, 2021;Seo et al, 2021). Patients with CRO infection had significantly higher ICU-LOS, treatment costs, and mortality rates (Tansarli et al, 2013;Birgand et al, 2016;Ho et al, 2016;Avendano et al, 2020;Merrick et al, 2021).…”

“…Recently, as a visualization tool, a nomogram based on multiple logistic regression was developed to predict the risk of CRE infection among liver transplantation recipients (Giannella et al, 2021) and patients in the intensive care unit (ICU) of a secondary referral hospital (Seo et al, 2021). However, there is no established risk prediction model for CRO infection among ICU patients.…”

Epidemiological characteristics of carbapenem-resistant Enterobacteriaceae and carbapenem-resistant Acinetobacter baumannii in a tertiary referral hospital in Korea

“…However, for hospitals to which a large number of patients are transferred, such as the hospital in this study, the application of active surveillance culture for all inpatients and outpatients would be burdensome in terms of time and cost. As an alternative, selectively performing active monitoring cultures for high-risk groups by applying a previously developed risk model can be considered [ 8 , 13 , 14 ].…”

“…Those studies also sought to describe the prevalence, incidence, and epidemiological characteristics of multidrug-resistant Gram-negative bacteria and CROs, including colonization and infection in ICUs, using data entered into a German infection monitoring system [ 12 ]. However, relatively few studies have been conducted in Korea; examples include a study aiming to identify risk factors for CRE colonization in patients admitted to the ICUs of general hospitals [ 13 , 14 ] and a study on the acquisition of carbapenem-resistant Escherichia coli in hospitalized patients [ 15 ]. These studies mainly targeted patients admitted to the ICU and focused on CRE.…”

Epidemiological Characteristics of Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae Colonization

“…According to recent studies, including systematic literature review studies, exposure to antibiotics, especially carbapenems, is the most important risk factor for CRE acquisition [10,11]. In addition, underlying diseases, invasive procedures including mechanical ventilation, use of medical devices such as central venous tubes, admission to intensive care units (ICUs) [11e13], multidrug-resistant organism (MDRO) colonization or infection [13], Acute Physiology and Chronic Health Evaluation (APACHE) II score [12,13], and transfer between hospitals [12] are related to CRE acquisition.…”