Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy.
Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.
Clin Infect Dis. 2021 Aug 16;73(4):e955-e966. doi: 10.1093/cid/ciab109.
Patients colonized with carbapenem-resistant Enterobacteriaceae (CRE) are at higher risk of developing CRE infection after liver transplantation (LT), with associated high morbidity and mortality. Prediction model for CRE infection after LT among carriers could be useful to target preventive strategies.
Multinational multicenter cohort study of consecutive adult patients underwent LT and colonized with CRE before or after LT, from January 2010 to December 2017. Risk factors for CRE infection were analyzed by univariate analysis and by Fine-Gray subdistribution hazard model, with death as competing event. A nomogram to predict 30- and 60-day CRE infection risk was created.
A total of 840 LT recipients found to be colonized with CRE before (n = 203) or after (n = 637) LT were enrolled. CRE infection was diagnosed in 250 (29.7%) patients within 19 (interquartile range [IQR], 9-42) days after LT. Pre- and post-LT colonization, multisite post-LT colonization, prolonged mechanical ventilation, acute renal injury, and surgical reintervention were retained in the prediction model. Median 30- and 60-day predicted risk was 15% (IQR, 11-24) and 21% (IQR, 15-33), respectively. Discrimination and prediction accuracy for CRE infection was acceptable on derivation (area under the curve [AUC], 74.6; Brier index, 16.3) and bootstrapped validation dataset (AUC, 73.9; Brier index, 16.6). Decision-curve analysis suggested net benefit of model-directed intervention over default strategies (treat all, treat none) when CRE infection probability exceeded 10%. The risk prediction model is freely available as mobile application at https://idbologna.shinyapps.io/CREPostOLTPredictionModel/.
Our clinical prediction tool could enable better targeting interventions for CRE infection after transplant.
携带碳青霉烯类耐药肠杆菌科（CRE）的患者在肝移植（LT）后发生 CRE 感染的风险更高，相关发病率和死亡率也很高。针对携带者的 LT 后 CRE 感染预测模型可能有助于确定预防策略的目标。
这是一项 2010 年 1 月至 2017 年 12 月期间进行的多国多中心连续成年 LT 患者队列研究，这些患者在 LT 前或 LT 后携带 CRE。使用单因素分析和 Fine-Gray 亚分布风险模型分析 CRE 感染的危险因素，以死亡为竞争事件。创建了一个预测 30 天和 60 天 CRE 感染风险的列线图。
共纳入 840 例 LT 受者，其中 203 例 LT 前（n = 203）或 LT 后（n = 637）定植 CRE。LT 后 19 天（IQR，9-42）内诊断出 250 例（29.7%）患者 CRE 感染。LT 前和 LT 后定植、LT 后多部位定植、机械通气时间延长、急性肾损伤和再次手术干预保留在预测模型中。中位 30 天和 60 天预测风险分别为 15%（IQR，11-24）和 21%（IQR，15-33）。在推导数据集（AUC，74.6；Brier 指数，16.3）和 bootstrap 验证数据集（AUC，73.9；Brier 指数，16.6）中，CRE 感染的区分度和预测准确性均可接受。决策曲线分析表明，当 CRE 感染概率超过 10%时，模型指导干预的净收益优于默认策略（全部治疗，全部不治疗）。该风险预测模型可在 https://idbologna.shinyapps.io/CREPostOLTPredictionModel/ 上作为移动应用程序免费获得。
我们的临床预测工具可以更好地针对移植后 CRE 感染进行干预。
