EviMed Research Group, LLC, PO Box 303, Goshen, MA, 01032, USA.
OptiStatim, LLC, 25 Willow Circle, Longmeadow, MA, 01106, USA.
BMC Infect Dis. 2021 Feb 8;21(1):159. doi: 10.1186/s12879-021-05842-0.
Complicated urinary tract infection (cUTI) is common among hospitalized patients. Though carbapenems are an effective treatment in the face of rising resistance, overuse drives carbapenem resistance (CR). We hypothesized that resistance to routinely used antimicrobials is common, and, despite frequent use of carbapenems, associated with an increased risk of inappropriate empiric treatment (IET), which in turn worsens clinical outcomes.
We conducted a retrospective cohort study of patients hospitalized with a culture-positive non-CR cUTI. Triple resistance (TR) was defined as resistance to > 3 of the following: 3rd generation cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, and nitrofurantoin. Multivariable models quantified the impact of TR and inappropriate empiric therapy (IET) on mortality, hospital LOS, and costs.
Among 23,331 patients with cUTI, 3040 (13.0%) had a TR pathogen. Compared to patients with non-TR, those with TR were more likely male (57.6% vs. 47.7%, p < 0.001), black (17.9% vs. 13.6%, p < 0.001), and in the South (46.3% vs. 41.5%, p < 0.001). Patients with TR had higher chronic (median [IQR] Charlson score 3 [2, 4] vs. 2 [1, 4], p < 0.001) and acute (mechanical ventilation 7.0% vs. 5.0%, p < 0.001; ICU admission 22.3% vs. 18.6%, p < 0.001) disease burden. Despite greater prevalence of empiric carbapenem exposure (43.3% vs. 16.2%, p < 0.001), patient with TR were also more likely to receive IET (19.6% vs. 5.4%, p < 0.001) than those with non-TR. Although mortality was similar between groups, TR added 0.38 (95% CI 0.18, 0.49) days to LOS, and $754 (95% CI $406, $1103) to hospital costs. Both TR and IET impacted the outcomes among cUTI patients whose UTI was not catheter-associated (CAUTI), but had no effect on outcomes in CAUTI.
TR occurs in 1 in 8 patients hospitalized with cUTI. It is associated with an increase in the risk of IET exposure, as well as a modest attributable prolongation of LOS and increase in total costs, particularly in the setting of non-CAUTI.
复杂尿路感染（cUTI）在住院患者中很常见。尽管碳青霉烯类药物在面对不断上升的耐药性时是一种有效的治疗方法，但过度使用会导致碳青霉烯类耐药（CR）。我们假设，常规使用的抗菌药物的耐药性很常见，尽管经常使用碳青霉烯类药物，但与不适当的经验性治疗（IET）的风险增加有关，这反过来又会恶化临床结果。
我们对患有培养阳性非 CR cUTI 的住院患者进行了回顾性队列研究。三重耐药（TR）定义为对以下 3 种以上药物耐药：第三代头孢菌素、氟喹诺酮类药物、复方磺胺甲噁唑、磷霉素和呋喃妥因。多变量模型量化了 TR 和不适当经验性治疗（IET）对死亡率、住院时间和成本的影响。
在 23331 例 cUTI 患者中，3040 例（13.0%）有 TR 病原体。与非 TR 患者相比，TR 患者更可能为男性（57.6% vs. 47.7%，p<0.001）、黑人（17.9% vs. 13.6%，p<0.001）和南方人（46.3% vs. 41.5%，p<0.001）。TR 患者的慢性（中位数[IQR]Charlson 评分 3[2,4] vs. 2[1,4]，p<0.001）和急性（机械通气 7.0% vs. 5.0%，p<0.001；ICU 入院 22.3% vs. 18.6%，p<0.001）疾病负担更高。尽管经验性碳青霉烯类药物暴露的患病率更高（43.3% vs. 16.2%，p<0.001），但 TR 患者也更有可能接受 IET（19.6% vs. 5.4%，p<0.001），而不是非 TR 患者。尽管两组死亡率相似，但 TR 使 LOS 延长 0.38 天（95%CI 0.18，0.49），使住院费用增加 754 美元（95%CI 406 美元，1103 美元）。TR 和 IET 都影响了非导管相关性尿路感染（CAUTI）患者的尿路感染结局，但对 CAUTI 患者的结局没有影响。
在因 cUTI 住院的患者中，每 8 人中就有 1 人出现 TR。它与 IET 暴露风险增加有关，并且会导致 LOS 适度延长和总费用增加，特别是在非 CAUTI 的情况下。
