Recent Exposure to Antimicrobials and Carbapenem-Resistant Enterobacteriaceae: The Role of Antimicrobial Stewardship

Abstract

BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) are rapidly emerging worldwide. Control group selection is critically important when analyzing predictors of antimicrobial resistance. Focusing on modifiable risk factors can optimize prevention and resource expenditures. To identify specific predictors of CRE, patients with CRE were compared with 3 control groups: (1) patients with extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae, (2) patients with non-ESBL-containing Enterobacteriaceae, and (3) uninfected controls. DESIGN Matched multivariable analyses. PATIENTS AND SETTING Patients possessing CRE that were isolated at Detroit Medical Center from September 1, 2008, to August 31, 2009. METHODS Patients were matched (1 : 1 ratio) to the 3 sets of controls. Matching parameters included (1) bacteria type, (2) hospital/facility, (3) unit/clinic, (4) calendar year, and (5) time at risk (ie, from admission to culture). Matched multivariable analyses were conducted between uninfected controls and patients with CRE, ESBL, and non-ESBL Enterobacteriaceae. Models were also designed comparing patients with CRE to patients with ESBL, patients with non-ESBL Enterobacteriaceae, and all 3 non-CRE groups combined. RESULTS Ninety-one unique patients with CRE were identified, and 6 matched models were constructed. Recent (less than 3 months) exposure to antibiotics was the only parameter that was consistently associated with CRE, regardless of the group to which CRE was compared, and was not independently associated with isolation of ESBL or non-ESBL Enterobacteriaceae. CONCLUSIONS Exposure to antibiotics within 3 months was an independent predictor that characterized patients with CRE isolation. As a result, antimicrobial stewardship efforts need to become a major focus of preventive interventions. Regulatory focus regarding appropriate antimicrobial use might decrease the detrimental effects of antibiotic misuse and spread of CRE.

Extended- Versus Narrower-Spectrum Antibiotics for Appendicitis

“…12 However, avoiding extended-spectrum antibiotics is preferable when possible, due both to increased cost and the association between their use and development of antibiotic-resistant infections. 4,18 Furthermore, appendicitis is a top contributor to antibiotic use in hospitalized children. 1 Local guidelines have successfully standardized appendicitis care, suggesting that antimicrobial stewardship programs could support selecting narrowerspectrum antibiotics for children with appendicitis (and particularly uncomplicated appendicitis) whenever appropriate.…”

“…Although the guidelines for complicated intraabdominal infections in adults state that narrower-spectrum regimens are "preferable to regimens with substantial antipseudomonal activity, " pediatric recommendations are less definitive; narrower-spectrum regimens (eg, cefoxitin) and extended-spectrum regimens (eg, piperacillin/tazobactam) are listed as equivalent choices for children with community-acquired, complicated intra-abdominal infections, including ruptured appendicitis. 3 Furthermore, extended-spectrum antibiotic use increases antimicrobial resistance, 4 and resistant infections are associated with increased morbidity, mortality, and health care costs. [5][6][7] Appendicitis is a high-priority condition for pediatric comparative effectiveness studies.…”

Molecular and Epidemiological Characterization of IMP-Type Metallo-β-Lactamase-Producing Enterobacter cloacae in a Large Tertiary Care Hospital in Japan

“…Carbapenemase (e.g., IMP, VIM, KPC, and NDM)-producing E. cloacae isolates have been reported (2,3,9,12). However, to the best of our knowledge, the risk factors, epidemiology, and clinical effects pertaining to IMP-type MBL-producing E. cloacae have not been systematically evaluated, in contrast to other carbapenemase-producing pathogens, such as KPC producers (13,14).…”

Multidrug-Resistant Tuberculosis Complicated by Nosocomial Infection with Multidrug-Resistant Enterobacteriaceae

“…6 In general, the use of antimicrobial therapy has provided continuous selection pressure of drug-resistant bacteria, such as in the case of carbapenem-resistant Enterobacteriaceae. 7 Apart from selection of resistant microorganisms due to antimicrobial pressure, these organisms can also be imported from high-prevalence areas around the world. While the prevalence of ESBL-producing Enterobacteriaceae carriage among the Dutch population is low with 5.1%, 8 a study reports 48% prevalence in northern India, the region of origin of our first patient.…”