Colonization and infection with extended-spectrum β-lactamase-producing Enterobacteriaceae in ICU patients: what impact on outcomes and carbapenem exposure?

Barbier, François; Pommier, C; Essaied, W; Garrouste-Orgeas, Maïté; Schwebel, Carole; Ruckly, Stéphane; Dumenil, AS; Lemiale,; Mourvillier, Bruno; Clec’h, Christophe; Darmon, Michaël; Laurent,; Marcotte, Guillaume; Jc, Lucet; Souweine, Bertrand; Zahar,; Jf, Timsit

doi:10.1093/jac/dkv423

Cited by 76 publications

(84 citation statements)

References 37 publications

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“…Only 7% of ESBL-PE carriers developed ESBL-PE pneumonia in our study, in keeping with previous studies [15]. By comparison, in the 15-month period between January 2014 and the end of the study (March 2015), 49 (4%) of 1192 patients without ESBL-PE colonization developed ICUAP.…”

Section: Discussionsupporting

confidence: 91%

“…ESBL-PE carriage has been recently associated with higher carbapenem exposure than in non-carriers, even in the absence of infection [15]. Using carbapenem for all suspected pneumonia in ESBL-colonized patients may foster the emergence and spread of carbapenem-resistant bacteria [8, 23], which may in turn result in inappropriate therapy when secondary infection is caused by carbapenem-resistant non-fermenting gram-negative bacilli, as illustrated in our series in which most patients not having ESBL-PE infection essentially had P. aeruginosa infection, some of which were carbapenem resistant.…”

Section: Discussionmentioning

confidence: 99%

“…However, infection with ESBL-PE was not an independent predictor of mortality. Barbier et al [15] recently found that infection with ESBL-PE was a predictor of fatal outcome in critically ill patients. However, the impact of ESBL resistance on mortality remains controversial and was not supported by other studies in ICUs [24, 25].…”

Section: Discussionmentioning

confidence: 99%

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Frequency, associated factors and outcome of multi-drug-resistant intensive care unit-acquired pneumonia among patients colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae

Razazi

Dessap

Carteaux

et al. 2017

Ann. Intensive Care

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Background We assessed prevalence, associated factors and prognosis of extended-spectrum beta-lactamase-producing Enterobacteriaceae pneumonia acquired in intensive care unit (ESBL-PE pneumonia) among carriers. Variables associated with nosocomial pneumonia caused by carbapenem-resistant bacteria (CRB) were also assessed.Methods A 6-year prospective study (May 2009–March 2015) in the medical ICU of an 850-bed university-affiliated hospital was conducted.Results Of the 6303 patients admitted, 843 (13.4%) had ESBL-PE carriage detected. Among carriers, 111 (13%) patients developed ICU-acquired pneumonia of whom 48 (43%) had ESBL-PE pneumonia (6% of carriers). By multivariable analysis, SAPS II at admission >43 [OR 2.81 (1.16–6.79)] and colonization with Enterobacter sp. or K. pneumoniae species [OR 10.96 (2.93–41.0)] were independent predictive factors for ESBL-PE pneumonia in colonized patients, whereas receipt of >2 days of amoxicillin/clavulanic acid during the ICU stay [OR 0.24 (0.08–0.71)] was protective. Patients with ESBL-PE pneumonia had a higher SOFA score (p = 0.037) and more frequent septic shock at pneumonia onset (p = 0.047). However, ESBL-PE pneumonia was not an independent predictor of mortality. Twenty-five patients had pneumonia caused by CRB. Chronic renal insufficiency, administration of third-generation cephalosporin within the past 3 months, acute respiratory distress syndrome before pneumonia and prior therapy with a carbapenem or fluoroquinolones were associated with CRB pneumonia in this selected population.ConclusionsAlthough few ESBL-PE carriers developed ESBL-PE pneumonia overall, a high proportion of pneumonia were caused by ESBL-PE in carriers developing ICUAP. ESBL-PE pneumonia was not an independent predictor of mortality. As pneumonia caused by CRB is increasing, knowledge of factors associated with ESBL-PE or CRB pneumonia may help empiric therapy of pneumonia among ESBL-PE carriers.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0283-4) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

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Frequency, associated factors and outcome of multi-drug-resistant intensive care unit-acquired pneumonia among patients colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae

Razazi

Dessap

Carteaux

et al. 2017

Ann. Intensive Care

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“…This prevalence is much higher than the 3.5% recently reported by Barbier et al [16], but the latter study was performed in a historical cohort (1996–2016) of 16,734 patients admitted to 17 French ICUs and ESBL prevalence has changed dramatically in the last two decades. Although we noted no relation between severity at admission and imported ESBL, Alves et al recently reported a lower rate of imported ESBL carriage of 8% in 308 patients with a much lower severity than in our population [17].…”

Section: Discussionmentioning

confidence: 58%

Epidemiology of extended-spectrum beta-lactamase-producing Enterobacteriaceae in an intensive care unit with no single rooms

Repessé

Artiguenave

Paktoris-Papine

et al. 2017

Ann. Intensive Care

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Background:The transmission of extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBL) is prevented by additional contact precautions, mainly relying on isolation in a single room and hand hygiene. Contact isolation cannot be achieved in our 12-bed ICU, which has only double rooms. We report the epidemiology of ESBL imported, acquired and transmitted in an ICU with no single rooms. Methods:We prospectively conducted an observational and non-interventional study in a French 12-bed ICU. Inclusion criteria were patients >18 years of age treated by at least two successive nursing teams. Patient characteristics at admission and clinical data during hospital stay were collected prospectively. ESBL carriage was monitored using rectal swabs collected at admission and once weekly during the ICU stay. Potential cross-transmission was studied (1) by identifying index patients defined as possible ESBL sources for transmission, (2) by classifying each ESBL strain according to the cefotaximase München (CTX M ) 1 and 9 groups and (3) by gene sequencing for remaining cases of possible transmission.Results: From June 2014 to April 2015, of 550 patients admitted to the ICU, 470 met the inclusion criteria and 221 had at least two rectal swabs. The rate of ESBL colonization, mainly by Escherichia coli, at admission was 13.2%. The incidence of ESBL acquisition, mainly with E. coli too, was 4.1%. Mortality did not differ between ESBL carriers and noncarriers. In univariate analysis, ESBL acquisition was associated with male gender, SAPS II, SOFA, chronic kidney disease at admission, duration of mechanical ventilation, need for catecholamine and the ICU LOS. In multivariate analysis, SAPS II at admission was the only risk factor for ESBL acquisition. We confirmed cross-transmission, emanating from the same index patient, in two of the nine patients with ESBL acquisition (0.8%, 2/221). No case of cross-transmission in the same double room was observed. Discussion and conclusion: Prevalence of ESBL colonization in our ICU was 13.2%. Despite the absence single rooms, the incidence of ESBL acquisition was 4.1% and cross-transmission was proven in only two cases, resulting from the same index patient who was not hospitalized in the same double room.

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“…Indeed, ESBLE carriage in otherwise uninfected critically ill patients has been associated with a three-fold increase in the empirical use of carbapenems during the ICU stay when compared to non-carriers [9]. Yet, documented absence of carriage might be used to withhold maximum broad-spectrum antibiotics in case of infection [10], and the development of rapid diagnostic tools-including phenotypic methods, mass spectrometry, or PCR-based assays-for earlier identification of pathogens and resistance patterns offers promising perspectives to target narrower-spectrum empirical therapy [6].…”

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confidence: 99%

In 2035, will all bacteria be multidrug-resistant? No

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Colonization and infection with extended-spectrum β-lactamase-producing Enterobacteriaceae in ICU patients: what impact on outcomes and carbapenem exposure?

Cited by 76 publications

References 37 publications

Frequency, associated factors and outcome of multi-drug-resistant intensive care unit-acquired pneumonia among patients colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae

Frequency, associated factors and outcome of multi-drug-resistant intensive care unit-acquired pneumonia among patients colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae

Epidemiology of extended-spectrum beta-lactamase-producing Enterobacteriaceae in an intensive care unit with no single rooms

In 2035, will all bacteria be multidrug-resistant? No

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