Validation of the INCREMENT‐SOT‐CPE score in a large cohort of liver transplant recipients with carbapenem‐resistant Enterobacterales infection

Abstract

Background Management of infections due to carbapenemase‐resistant Enterobacterales (CRE) in solid organ transplant (SOT) recipients remains a difficult challenge. The INCREMENT‐SOT‐CPE score has been specifically developed from SOT recipients to stratify mortality risk, but an external validation is lacking. Methods Multicenter retrospective cohort study of liver transplant (LT) recipients colonized with CRE infection who developed infection after transplant over 7‐year period. Primary endpoint was all‐cause 30‐day mortality from infection onset. A comparison between INCREMENT‐SOT‐CPE and other selected scores was performed. A two‐level mixed effects logistic regression model with random effects for the center was fitted. Performance characteristics at optimal cut‐point were calculated. Multivariable Cox regression analysis of risk factors for all‐cause 30‐day mortality was carried out. Results Overall, 250 CRE carriers developed infection after LT and were analyzed. The median age was 55 years (interquartile range [IQR]: 46–62) and 157 were males (62.8%). All‐cause 30‐day mortality was 35.6%. A sequential organ failure assessment (SOFA) score ≥ 11 showed a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 69.7%, 76.4%, 62.0%, 82.0%, and 74.0%, respectively. An INCREMENT‐SOT‐CPE ≥ 11 reported a sensitivity, specificity, PPV, NPV, and accuracy of 73.0%, 62.1%, 51.6%, 80.6% and 66.0%, respectively. At multivariable analysis acute renal failure, prolonged mechanical ventilation, INCREMENT‐SOT‐CPE score ≥ 11 and SOFA score ≥ 11 were independently associated with all‐cause 30‐day mortality, while a tigecycline‐based targeted regimen was found to be protective. Conclusions Both INCREMENT‐SOT‐CPE ≥ 11 and SOFA ≥ 11 were identified as strong predictors of all‐cause 30‐day mortality in a large cohort of CRE carriers developing infection after LT.

Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review

“…A more recent, large, multicenter, international cohort study [ 92 ] reported that among 840 CRE carriers, 29.8% developed a CRE infection within 30 days post-LT; distributed as BSI (36.5%), SSI (26%), and lower respiratory tract infections (23.6%).…”

“…A mortality risk score to predict 30-day mortality (INCREMENT-SOT-CPE [ 94 ]) was developed and validated [ 92 ]. The INCREMENT-SOT-CPE [ 8 ] score takes in consideration INCREMENT-CPE mortality score ≥8, no source control, inappropriate empirical therapy, cytomegalovirus disease, and lymphopenia.…”

Mortality due to carbapenemase‐producing GNB in transplantation: Are risk scores useful?

“…As toxicity is not a major concern, current restrictions for the incorporation of this and other new antimicrobials in empirical schemes are mainly supported by the aim of the protection of these new precious alternatives against the emergence of multirresistance in the grounds of antibiotic stewardship programs. 1,7 In the study of Rinaldi et al, 8 the INCREMENT-SOT score is a subject of external validation in liver transplant recipients with different types of infections due to CPE. The INCREMENT-SOT score was designed as a tool that could aid in the selection of SOT recipients with CPE bloodstream infections with the highest risk of 30-day mortality and, therefore, candidates the best available combination therapies when infection is suspected.…”

“…In the study of Rinaldi et al., 8 the INCREMENT‐SOT score is a subject of external validation in liver transplant recipients with different types of infections due to CPE. The INCREMENT‐SOT score was designed as a tool that could aid in the selection of SOT recipients with CPE bloodstream infections with the highest risk of 30‐day mortality and, therefore, candidates the best available combination therapies when infection is suspected 9 .…”