Frequency, associated factors and outcome of multi-drug-resistant intensive care unit-acquired pneumonia among patients colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae

Abstract

Background We assessed prevalence, associated factors and prognosis of extended-spectrum beta-lactamase-producing Enterobacteriaceae pneumonia acquired in intensive care unit (ESBL-PE pneumonia) among carriers. Variables associated with nosocomial pneumonia caused by carbapenem-resistant bacteria (CRB) were also assessed.Methods A 6-year prospective study (May 2009–March 2015) in the medical ICU of an 850-bed university-affiliated hospital was conducted.Results Of the 6303 patients admitted, 843 (13.4%) had ESBL-PE carriage detected. Among carriers, 111 (13%) patients developed ICU-acquired pneumonia of whom 48 (43%) had ESBL-PE pneumonia (6% of carriers). By multivariable analysis, SAPS II at admission >43 [OR 2.81 (1.16–6.79)] and colonization with Enterobacter sp. or K. pneumoniae species [OR 10.96 (2.93–41.0)] were independent predictive factors for ESBL-PE pneumonia in colonized patients, whereas receipt of >2 days of amoxicillin/clavulanic acid during the ICU stay [OR 0.24 (0.08–0.71)] was protective. Patients with ESBL-PE pneumonia had a higher SOFA score (p = 0.037) and more frequent septic shock at pneumonia onset (p = 0.047). However, ESBL-PE pneumonia was not an independent predictor of mortality. Twenty-five patients had pneumonia caused by CRB. Chronic renal insufficiency, administration of third-generation cephalosporin within the past 3 months, acute respiratory distress syndrome before pneumonia and prior therapy with a carbapenem or fluoroquinolones were associated with CRB pneumonia in this selected population.ConclusionsAlthough few ESBL-PE carriers developed ESBL-PE pneumonia overall, a high proportion of pneumonia were caused by ESBL-PE in carriers developing ICUAP. ESBL-PE pneumonia was not an independent predictor of mortality. As pneumonia caused by CRB is increasing, knowledge of factors associated with ESBL-PE or CRB pneumonia may help empiric therapy of pneumonia among ESBL-PE carriers.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0283-4) contains supplementary material, which is available to authorized users.

Ventilator-associated pneumonia in adults: a narrative review

“…May be associated with lower mortality rates. Most benefit likely from minimizing sedation and encouraging early extubation to take into account this pathogen in the empirical antimicrobial treatment [135,136]. Moreover, it has been shown that 63% of infection-related ventilator-associated complications were neither VAP nor attributable to a documented ICU infection [136], indicating that efforts should be concentrated on the diagnostic strategy, to use carbapenems only in patients with true infection, and to withhold carbapenems when the likelihood of infection is low.…”

Microbial cause of ICU-acquired pneumonia: hospital-acquired pneumonia versus ventilator-associated pneumonia

“…They now represent 19 to 61% of the episodes, varying according to species and to countries [8,18]. Several studies suggest that previous colonization and antibiotic therapy are the two most important risk factors associated with ESBL-PE related infection [19,20]. In a study conducted in 587 patients with suspected VAP, 40 patients (6.8%) were colonized with ESBL-PE prior to the development of pneumonia and 20 (3.4%) had VAP caused by this microorganism, of whom 17 were previously colonized with ESBL-PE [21].…”

Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase–producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies

“…This pandemic drives a continuous influx of ESBL-E into the hospital system that adds to the pool of inpatients colonized with healthcare-associated lineages. Thus, carriage prevalence at ICU admission is rapidly increasing, and now commonly reaches 10-15% in Europe and up to 40% in certain Asian countries [6], although marked fluctuations are observed depending on the hospital location and case mix ( Supplementary Table S1). Of note, the prevalence of imported carriage in a given ICU has been linked to the likelihood of ESBL-E acquisition among patients not colonized at admission, a phenomenon referred as to colonization pressure [7,8].…”

“…Overall, ESBL-E infections occur during ICU stays in only 10 to 25% of critically-ill patients with intestinal colonization [4,6,26,31]. In those receiving mechanical ventilation, ESBL-E are responsible for ~40% of ventilator-associated pneumonia (VAP) [6,32], while accounting for merely 7% of infection-related ventilator-associated complications [33]. Therefore, in an era of growing prevalence of colonization, identifying those carriers at risk for infection constitutes a pivotal challenge for carbapenem sparing in the ICU.…”

“…Therefore, in an era of growing prevalence of colonization, identifying those carriers at risk for infection constitutes a pivotal challenge for carbapenem sparing in the ICU. Studies that focused on this issue yielded conflicting results on the predictive role of clinical parameters, such as prior length of the ICU stay, previous exposure to non-carbapenem antimicrobials (including beta-lactam/beta-lactamase inhibitor combinations, third-generation cephalosporins, or fluoroquinolones), or imported versus ICU-acquired carriage [6,31,33]. Patients colonized with ESBL-producing K. pneumoniae or Enterobacter spp.…”