Carbapenem-Nonsusceptible Gram-Negative Pathogens in ICU and Non-ICU Settings in US Hospitals in 2017: A Multicenter Study

Abstract

BackgroundInfections caused by Gram-negative pathogens resistant to carbapenems have limited treatment options and are associated with increased morbidity and mortality. We evaluated the rates, infection sources, and pathogen types associated with carbapenem-nonsusceptible (Carb-NS) Gram-negative isolates in intensive care unit (ICU) and non-ICU settings in a large US hospital database.MethodsWe conducted a retrospective cross-sectional analysis of carbapenem susceptibility of all nonduplicate isolates of Gram-negative pathogens collected from January 1, 2017, to December 31, 2017, at 358 US hospitals in the BD Insights Research Database. Carb-NS isolates included all pathogens reported at the institutional level as intermediate or resistant.ResultsOf 312 075 nonduplicate Gram-negative isolates, 10 698 (3.4%) were Carb-NS. Respiratory samples were the most frequent source of Carb-NS isolates (35.2%); skin/wound accounted for 23.6%. Pseudomonas aeruginosa was the most common Carb-NS pathogen (58.5% of isolates), and about 30% were Enterobacteriaceae. The highest rates of Carb-NS were found in Acinetobacter spp. (35.6%) and P. aeruginosa (14.6%). The rate of Carb-NS was significantly higher in ICU (5.4%) vs non-ICU settings (2.7%; P < .0001 in univariate analysis). This difference remained significant in multivariable analysis after adjusting for infection and hospital characteristics (odds ratio, 1.35; 95% confidence interval, 1.17–1.56; P < .0001).ConclusionsInfections caused by Carb-NS isolates pose a significant clinical problem across different sources of infection, species of pathogen, and hospital settings. Widespread infection prevention and antimicrobial stewardship initiatives, in combination with new treatment options, may be required to reduce the burden of carbapenem resistance in health care settings.

National prevalence estimates for resistant Enterobacteriaceae and Acinetobacter species in hospitalized patients in the United States

“…NHSN Acinetobacter resistance rates for HAIs were also higher: 49.5% of tested Acinetobacter isolates were Carb-NS in 2014 data (Anon, 2015a) compared with 34.4% estimated here for inpatients. Consistent with these data, McCann et al observed a higher proportion of Carb-NS Gram-negative isolates in hospital-onset (6.8%) versus admission (2.4%) cultures in the BD Insights database (McCann et al, 2018).…”

“…Based on our data, isolates of the most common antibiotic-resistant phenotype in our study, ESBL Enterobacteriaceae, are present in 1 of every 141 inpatients. We have previously shown that a given isolate in our database may have multiple antibiotic-resistant phenotypes (for instance, Carb NS Enterobacteriaceae could potentially also be MDR) (McCann et al, 2018), so it is not appropriate to add inpatient rates from different resistance phenotypes to estimate an overall burden. Nevertheless, the ESBL figure alone indicates that the magnitude of resistant Enterobacteriaceae within US hospitals is substantial.…”

“…Reporting institutions consisted of US hospitals included in the BD Insights Research Database (Becton, Dickinson and Company, Franklin Lakes, NJ). The electronic surveillance system and clinical research database (formerly the CareFusion Clinical Research Database) have been previously described (Brossette et al, 2006;Ridgway et al, 2016;Tabak et al, 2013;McCann et al, 2018). This database provides good geographical representation across the US and includes both small and large hospitals in urban and rural areas (Table 1).…”

Molecular characterization of metallo-β-lactamase- producing carbapenem-resistant Enterobacter cloacae complex isolated in Heilongjiang Province of China

“…The significance of the global spread of carbapenemaseproducing ECC isolates through patient transfer or colonized travelers in Europe, North America, the Far East and Australia has been well described in two reviews [2,3]. Recent meta-analysis and multicenter clinical study demonstrated a more than two-fold increased risk of mortality in patients infected with carbapenem-resistant gram-negative, MDR-positive bacteria, and a significant increase in healthcare cost [4,5]. It has been reported that mortality rate in the patients with CRE infections was as high as 44% [6].…”

The Likelihood of Developing a Carbapenem-Resistant Enterobacteriaceae Infection during a Hospital Stay

“…the United States, with almost half of CRE infections consisting of carbapenemase producers (CP-CRE) (1)(2)(3). Patients hospitalized in the intensive care unit (ICU) setting are at particularly high risk of newly acquiring CRE during their hospital stay because the multiple preexisting medical conditions, compromised immune systems, lengthy unit stays, and significant rates of device and antibiotic utilization establish an ideal milieu for antibiotic resistance (4,5).…”