Risk Factors Associated With Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae Positive Cultures in a Cohort of US Veterans

Abstract

Introduction Carbapenem-resistant Enterobacterales (CRE) cause approximately 13,100 infections with 8% mortality in the United States annually. The subset of carbapenemase-producing CRE (CP-CRE) infections have much higher mortality rates (40% -50%). There has been little research on characteristics unique to CP-CRE. The goal of this study was to assess differences between those with nonCP-CRE and CP-CRE cultures in U.S. Veterans. Methods A retrospective cohort of Veterans with CRE cultures from 2013-2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE. Results 3,096 unique patients with cultures positive for either nonCP-CRE or CP-CRE were included. Being African American (Odds Ratio (OR)=1.44 (95% Confidence Interval (CI) 1.15,1.80), diagnosis in 2017 (OR=3.11 (95% CI 2.13,4.54)) or 2018 (OR=3.93 (95%CI 2.64,5.84)), congestive heart failure (OR=1.35 (95%CI 1.11,1.64)), and gastroesophageal reflux disease (OR=1.39 (95%CI 1.03,1.87)) were associated with CP-CRE cultures. 752 (24.3%) patients had no known antibiotic exposure in the year before culture; these individuals had a comparatively increased frequency of prolonged PPI use (17.3% vs 5.6%). Discussion Among a cohort of patients with CRE, African Americans, individuals with congestive heart failure, and patients with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly one in four patients with CP-CRE had no known antibiotic exposure in the year before their positive culture.

Antibiotic susceptibility patterns of viridans group streptococci isolates in the United States from 2010 to 2020

“…Antibiotic susceptibility data for VGS isolates from patients, and their demographic, medical and facility level covariates were obtained retrospectively from VA Medical Centers, as previously described. 11 Streptococcus mitis , Streptococcus oralis and non-speciated VGS isolates with susceptibility data collected between 2010 and 2020 at 122 VA Medical Centers across the United States were included. Susceptibility data originated from testing performed by each VA Medical Center and were pulled from the electronic medical records via the Corporate Data Warehouse.…”

Epidemiological Characteristics of Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae Colonization

“…This result is similar to the 20.0% CP-CRE-positive rate [17] obtained in a study in patients with CRE admitted to ICUs and transplant wards of a single hospital in the United States. However, it is much lower than the 27.7% [18] reported in a study using a cohort of patients admitted to 127 veterans hospitals in the United States and the 31.5% reported by the US Centers for Disease Control and Prevention' Antibiotic Resistance Laboratory Network [30], and 44.7% of national surveillance report using both active surveillance cultures and clinical samples from 189 institutions in Korea [31]. This result may be related to the difference in the sample mix; colonized by or infected with CRE.…”

“…According to previous studies, the positivity rate for CP-CRE differs depending on the CRE-infected or colonized patients varies widely from 20% [17] to 67.9% [18]. CP-CRE-related characteristics also showed different results depending on which of the CREinfected or colonized patients were targeted.…”

“…In a case-control study in which patients with CRE bacteremia were classified into CP-CRE and non-CP-CRE groups in China, old age, cancer, and use of carbapenem antibiotics were identified as risk factors for CP-CRE [19]. In a cohort study of US veterans, heart disease and gastroesophageal reflux disease [18] were identified as risk factors for CP-CRE. In contrast, in a study that divided patients with CRE into CP-CRE and non-CP-CRE groups at an Israeli tertiary hospital, prehospital antibiotic use, experience in nursing homes, and the presence or absence of pressure sores were identified as risk factors for CP-CRE; age was not a risk factor [20].…”

Carbapenem-Resistant enterobacterales in individuals with and without health care risk factors —Emerging infections program, United States, 2012-2015

“…41 Lastly, the Department of Veterans Affaris demonstrated that among a retrospective cohort of patients with CRE, more persons of White race were identified; however, among the subset with CP-CRE, patients were significantly more likely to be of African American or Black race. 42 A carbapenemase gene was identified in 5 of the 12 CA-CRE isolates that underwent whole genome sequencing at the CDC, KPC being the most commonly identified gene (n = 4). In the United States, acquisition of CRE harboring carbapenemase enzymes is commonly linked to inpatient health care exposures, and among the carbapenemase KPC is the gene most commonly identified.…”