McConville Thomas Howe, Sullivan Sean Berger, Gomez-Simmonds Angela, Whittier Susan, Uhlemann Anne-Catrin
Department of Medicine, Division of Infectious Diseases, Columbia University Medical Center, New York, New York, United States of America.
Department of Pathology and Cell Biology, Clinical Microbiology Laboratory, Columbia University Medical Center, New York, New York, United States of America.
PLoS One. 2017 Oct 12;12(10):e0186195. doi: 10.1371/journal.pone.0186195. eCollection 2017.
Carbapenem-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).
We 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).
Among 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).
Our 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.
耐碳青霉烯类肠杆菌科细菌（CRE）已成为紧迫的公共卫生威胁。CRE肠道定植已被确定为全身性CRE感染发生的一个危险因素，但尚未与第三代和/或第四代头孢菌素耐药（Ceph-R）肠杆菌科细菌的定植进行比较。此外，定植对不良结局的风险尚不明确，尤其是在入住重症监护病房（ICU）的重症患者中。
我们对2013年4月至7月期间入住ICU时接受CRE或Ceph-R直肠定植筛查的成年连续患者进行了一项队列研究。我们确定了临床变量，并评估了CRE或Ceph-R定植与30天内随后发生的全身性CRE感染（主要结局）和90天内全因死亡率（次要结局）之间的关系。
在338例ICU患者中，94例（28%）被Ceph-R或CRE定植。26例患者在拭子采集后30天内发生了CRE感染；CRE定植患者中有47%（N = 17/36），Ceph-R定植患者中有3%（N = 2/58）。CRE定植患者中有36%（N = 13/36）在90天内死亡，相比之下，Ceph-R定植患者为31%（N = 18/58），未定植患者为15%（N = 37/244）。在多变量分析中，CRE定植独立预测30天时全身性CRE感染的发生（校正比值比[aOR] 10.8，95%置信区间[CI] 2.8 - 41.9，p = 0.0006）；Ceph-R定植则无此关联（aOR 0.5，95% CI 0.1 - 3.3，p = 0.5）。在单变量分析中，CRE定植与90天死亡率增加相关（p值0.001），在多变量模型中，既往住院和入住医疗ICU是90天死亡率的独立预测因素，而CRE定植接近显著水平（aOR 2.3，95% CI 1.0 - 5.3，p = 0.056）。
我们的研究强调了入住ICU时CRE定植患者发生CRE感染和死亡的风险增加。未来需要开展研究以评估CRE定植如何指导经验性抗生素选择，并制定新的去定植策略。
