Increased mortality in hospital- compared to community-onset carbapenem-resistant enterobacterales infections
Author:
Boutzoukas Angelique E12, Mackow Natalie3, Giri Abhigya4, Komarow Lauren4, Hill Carol2, Chen Liang5, Doi Yohei67ORCID, Satlin Michael J8, Arias Cesar910, Wang Minggui11ORCID, Mora Moreo Laura12, Herc Erica13, Cober Eric14, Weston Gregory15ORCID, Patel Robin16ORCID, Bonomo Robert A17181920, Fowler Vance221, van Duin David3ORCID, , Banerjee Ritu, Boucher Helen, Chambers Henry ‘Chip’, Cosgrove Sara, Cross Heather, Doernberg Sarah, Dixon Dennis, Evans Scott, Ghazaryan Varduhi, Hamasaki Toshi, Hanson Kim, Harris Anthony, Holland Thomas, Lautenbach Ebbing, Lodise Tom, Mehigan Maureen, Moon Kyung, Paterson David, Pettigrew Melinda, Raterman Erica, Samuel Tamika, Shelburne Sam, Zou Lanling, , Kanj Souha S, Jabbour Jean Francois (Jeff), Zhang Fujie, Lok Judith J, Salata Robert A, Stryjewski Martin, Castelnuovo Valentina Di, Gutierrez Jose Millan Oñate, Cober Eric, Richter Susan, Anderson Deverick J, Evans Beth, Hill Carol, Cross Heather R, Baum Keri, Arias Rebekka, Fowler Vance G, Ordoñez Karen, Jacob Jesse T, Li Linghua, Kreiswirth Barry N, Manca Claudia, Chen Liang, Desai Samit, Herc Erica, Cordova Ezequiel, Rioseco Maria, Vichez Samuel, Sanchez Marisa L, Valderrama Sandra, Figueroa Jairo, Arias Cesar A, Dinh An Q, Panesso Diane, Rydell Kirsten, Tran Truc T, Hu Fupin, Su Jiachun, Jiang Jianping, Wang Minggui, Xu Xiaogang, Yang Yang, Munita Jose M, Spencer Maria, Alenazi Thamer, Bonomo Robert A, Marshall Steven H, Rudin Susan D, Huskins Charles, Kerry , Revolinski Sara, Wortmann Glenn, Kalayjian Robert C, Weston Greg, Ostrowsky Belinda, Patel Gopi, Eiras Daniel, Kim Angela, Garcia-Diaz Julia, Salcedo Soraya, Farrell John J, Liu Zhengyin, Henderson Andrew, Paterson David L, Xie Qing, Kaye Keith S, Gao Hainv, Yu Yunsong, Waters Mary, Fries Bettina C, Eilertson Brandon, Marimuthu Kalisvar, Chew Kean Lee, Smitasin Nares, Tambyah Paul Ananth, Gallagher Jason C, Peleg Anton, Leroi Marcel, Li Lanjuan, Komarow Lauren, Ge Lizhao, Evans Scott, McCarty Todd, Chambers Henry F, Garner Omai B, Abbo Lilian M, Duin David van, Lautenbach Ebbing, Han Jennifer H, Doi Yohei, Wong Darren, Hanson Blake, Reyes Jinnethe, Botero Maria Virginia Villegas, Diaz Lorena, Perez Federico, Banerjee Ritu, Dhar Sorabh, Satlin Michael J, Zong Zhiyong
Affiliation:
1. Department of Pediatrics, Duke University , Durham, NC , USA 2. Duke Clinical Research Institute, Duke University , Durham, NC , USA 3. Division of Infectious Diseases, University of North Carolina , Chapel Hill, NC , USA 4. The Biostatistics Center, George Washington University , Rockville, MD , USA 5. Department of Medical Sciences, Hackensack Meridian School of Medicine, Center for Discovery and Innovation, Hackensack Meridian Health , Nutley, NJ , USA 6. Division of Infectious Diseases, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA 7. Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine , Aichi , Japan 8. Division of Infectious Diseases, Weill Cornell Medicine , New York, NY , USA 9. Division of Infectious Diseases and Center for Infectious Diseases Research, Houston Methodist Hospital and Houston Methodist Research Institute , Houston, TX , USA 10. Department of Medicine, Weill Cornell Medical College , New York, NY , USA 11. Institute of Antibiotics, Huashan Hospital, Fudan University , Shanghai , China 12. Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine , London , UK 13. Department of Medicine, Henry Ford Hospital , Detroit, MI , USA 14. Department of Infectious Diseases, Cleveland Clinic , Cleveland, OH , USA 15. Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine , Bronx, NY , USA 16. Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, and Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic , Rochester, MN , USA 17. Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center , Cleveland, OH , USA 18. Department of Medicine, Case Western Reserve University School of Medicine , Cleveland, OH , USA 19. Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine , Cleveland, OH , USA 20. CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES) , Cleveland, OH , USA 21. Division of Infectious Diseases, Duke University , Durham, NC , USA
Abstract
Abstract
Background
The CDC reported a 35% increase in hospital-onset (HO) carbapenem-resistant Enterobacterales (CRE) infections during the COVID-19 pandemic. We evaluated patient outcomes following HO and community-onset (CO) CRE bloodstream infections (BSI).
Methods
Patients prospectively enrolled in CRACKLE-2 from 56 hospitals in 10 countries between 30 April 2016 and 30 November 2019 with a CRE BSI were eligible. Infections were defined as CO or HO by CDC guidelines, and clinical characteristics and outcomes were compared. The primary outcome was desirability of outcome ranking (DOOR) 30 days after index culture. Difference in 30-day mortality was calculated with 95% CI.
Results
Among 891 patients with CRE BSI, 65% were HO (582/891). Compared to those with CO CRE, patients with HO CRE were younger [median 60 (Q1 42, Q3 70) years versus 65 (52, 74); P < 0.001], had fewer comorbidities [median Charlson comorbidity index 2 (1, 4) versus 3 (1, 5); P = 0.002] and were more acutely ill (Pitt bacteraemia score ≥4: 47% versus 32%; P < 0.001). The probability of a better DOOR outcome in a randomly selected patient with CO BSI compared to a patient with HO BSI was 60.6% (95% CI: 56.8%–64.3%). Mortality at 30-days was 12% higher in HO BSI (192/582; 33%) than CO BSI [66/309 (21%); P < 0.001].
Conclusion
We found a disproportionately greater impact on patient outcomes with HO compared to CO CRE BSIs; thus, the recently reported increases in HO CRE infections by CDC requires rigorous surveillance and infection prevention methods to prevent added mortality.
Funder
National Institutes for Allergy and Infectious Diseases National Institutes of Health NIH
Publisher
Oxford University Press (OUP)
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