Unique Risks and Clinical Outcomes Associated With Extended-Spectrum β-Lactamase Enterobacteriaceae in Veterans With Spinal Cord Injury or Disorder: A Case-Case-Control Study

Abstract

OBJECTIVES To describe the burden of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae in veterans with spinal cord injury or disorder (SCI/D), to identify risk factors for ESBL acquisition, and to assess impact on clinical outcomes DESIGN Retrospective case-case-control study PATIENTS AND SETTING Veterans with SCI/D and utilization at a Veterans' Affairs medical center from January 1, 2012, to December 31, 2013. METHODS Patients with a positive culture for ESBL Klebsiella pneumoniae, Escherichia coli, or Proteus mirabilis were matched with patients with non-ESBL organisms by organism, facility, and level of care and to uninfected controls by facility and level of care. Inpatients were also matched by time at risk. Univariate and multivariate matched models were assessed for differences in risk factors and outcomes. RESULTS A total of 492 cases (62.6% outpatients) were matched 1:1 with each comparison group. Recent prior use of fluoroquinolones and prior use of third- and fourth-generation cephalosporins were independently associated with ESBL compared to the non-ESBL group (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.77-3.84; P<.001 for fluoroquinolones and aOR, 3.86; 95% CI, 2.06-7.25; P<.001 for third- and fourth-generation cephalosporins) and the control group (aOR, 2.10; 95% CI, 1.29-3.43; P = .003 for fluoroquinolones; and aOR, 3.31; 95% CI, 1.56-7.06; P=.002 for third- and fourth-generation cephalosporins). Although there were no differences in mortality rate, the ESBL group had a longer post-culture length of stay (LOS) than the non-ESBL group (incidence rate ratio, 1.36; 95% CI, 1.13-1.63; P=.001). CONCLUSIONS All SCI/D patients with ESBL were more likely to have had recent exposure to fluoroquinolones or third- and fourth-generation cephalosporins, and hospitalized patients were more likely to have increased post-culture LOS. Programs targeted toward reduced antibiotic use in SCI/D patients may prevent subsequent ESBL acquisition. Infect Control Hosp Epidemiol 2016;37:768-776.

Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015

“…A recent hospitalization or extraoral infection was defined as occurring within 14 days before the antibiotic dispense date. 23 , 24 …”

Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions

“…7–9 Frequent courses of antibiotics put persons with SCI at risk of acquiring resistant pathogens, and it has been shown that the proportions of these pathogens are indeed high in populations with SCI. 10–12 …”

Prevalence and Factors Associated With Multidrug-Resistant Gram-Negative Organisms in Patients With Spinal Cord Injury

“…Complete injuries were more common in ESBL-and non-ESBL-producing Enterobacteriaceae than controls in a national case-case-control study of veterans with SCI. 29 A study of nursing home residents found that colonized cases of MDR A. baumannii occurred in persons who were more functionally disabled than controls. 30 We also found that those injured for a longer time had a lower prevalence of MDRGNOs, which was surprising, especially since older age was associated with MDRGNOs.…”