碳青霉烯类耐药肠杆菌科细菌感染所致归因死亡率：一项前瞻性、多国家病例对照对照匹配队列研究（EURECA）的结果。

Attributable mortality of infections caused by carbapenem-resistant Enterobacterales: results from a prospective, multinational case-control-control matched cohorts study (EURECA).

机构信息

Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Sevilla, Spain.

出版信息

Clin Microbiol Infect. 2024 Feb;30(2):223-230. doi: 10.1016/j.cmi.2023.11.008.

DOI:10.1016/j.cmi.2023.11.008

PMID:38267096

Abstract

OBJECTIVES

To assess the mortality attributable to infections caused by carbapenem-resistant Enterobacterales (CRE) and to investigate the effect of clinical management on differences in observed outcomes in a multinational matched cohort study.

METHODS

A prospective matched-cohorts study (NCT02709408) was performed in 50 European hospitals from March 2016 to November 2018. The main outcome was 30-day mortality with an active post-discharge follow-up when applied. The CRE cohort included patients with complicated urinary tract infections, complicated intra-abdominal infections, pneumonia, or bacteraemia from other sources because of CRE. Two control cohorts were selected: patients with infection caused by carbapenem-susceptible Enterobacterales (CSE) and patients without infection. Matching criteria included type of infection for the CSE group, hospital ward of CRE detection, and duration of hospital admission up to CRE detection. Multivariable and stratified Cox regression was applied.

RESULTS

The cohorts included 235 patients with CRE infection, 235 patients with CSE infection, and 705 non-infected patients. The 30-day mortality (95% CI) was 23.8% (18.8-29.6), 10.6% (7.2-15.2), and 8.4% (6.5-10.6), respectively. The difference in 30-day mortality rates between patients with CRE infection when compared with patients with CSE infection was 13.2% (95% CI, 6.3-20.0), (HR, 2.57; 95% CI, 1.55-4.26; p < 0.001), and 15.4% (95% CI, 10.5-20.2) when compared with non-infected patients (HR, 3.85; 95% CI, 2.57-5.77; p < 0.001). The population attributable fraction for 30-day mortality for CRE vs. CSE was 19.28%, and for CRE vs. non-infected patients was 9.61%. After adjustment for baseline variables, the HRs for mortality were 1.87 (95% CI, 0.99-3.50; p 0.06) and 3.65 (95% CI, 2.29-5.82; p < 0.001), respectively. However, when treatment-related time-dependent variables were added, the HR of CRE vs. CSE reduced to 1.44 (95% CI, 0.78-2.67; p 0.24).

DISCUSSION

CRE infections are associated with significant attributable mortality and increased adjusted hazard of mortality when compared with CSE infections or patients without infection. Underlying patient characteristics and a delay in appropriate treatment play an important role in the CRE mortality.

摘要

目的

评估耐碳青霉烯肠杆菌科（CRE）感染导致的死亡率，并通过一项多国匹配队列研究调查临床管理对观察结果差异的影响。

方法

2016 年 3 月至 2018 年 11 月，在 50 家欧洲医院进行了一项前瞻性匹配队列研究（NCT02709408）。主要结局为 30 天死亡率，并在适用时进行主动出院后随访。CRE 队列包括因 CRE 引起的复杂性尿路感染、复杂性腹腔内感染、肺炎或其他来源的菌血症患者。选择了两个对照队列：耐碳青霉烯类肠杆菌科（CSE）感染患者和无感染患者。匹配标准包括 CSE 组的感染类型、CRE 检测的医院病房和入院时间至 CRE 检测。应用多变量和分层 Cox 回归。

结果

该队列包括 235 例 CRE 感染患者、235 例 CSE 感染患者和 705 例无感染患者。30 天死亡率（95%CI）分别为 23.8%（18.8-29.6）、10.6%（7.2-15.2）和 8.4%（6.5-10.6）。与 CSE 感染患者相比，CRE 感染患者的 30 天死亡率差异为 13.2%（95%CI，6.3-20.0）（HR，2.57；95%CI，1.55-4.26；p<0.001），与无感染患者相比差异为 15.4%（95%CI，10.5-20.2）（HR，3.85；95%CI，2.57-5.77；p<0.001）。CRE 与 CSE 相比，30 天死亡率的人群归因分数为 19.28%，与无感染患者相比为 9.61%。在调整基线变量后，死亡率的 HR 分别为 1.87（95%CI，0.99-3.50；p=0.06）和 3.65（95%CI，2.29-5.82；p<0.001）。然而，当添加与治疗相关的时间依赖性变量时，CRE 与 CSE 的 HR 降低至 1.44（95%CI，0.78-2.67；p=0.24）。