Risk factors for bloodstream infections due to carbapenem-resistant Enterobacterales: a nested case-control-control study
Hongyu Zhou, Niccolò Buetti, Salvador Pérez-Galera, José María Bravo-Ferrer, Belén Gutiérrez‐Gutiérrez, María Paniagua‐García, Jan Feifel, Julien Sauser, Tomi Kostyanev, Rafael Cantón, Lionel Tan, Dimitris Basoulis, Vicente Pintado, Emmanuel Roilides, Gorana Dragovac, Julián Torre-Cisneros, Deana Medić, Murat Akova, Herman Goossens, Marc J. M. Bonten, Stephan Harbarth, Jesús Rodríguez‐Baño, Marlieke E.A. de Kraker, COMBACTE- EURECA project team, Jesús Sojo-Dorado, Almudena de la Serna, Sophie Monteau, Virginia Palomo, Elena Soriano, David Gutiérrez, Elisa Moreno, Zaira Palacios, Isabel Morales, Natália Maldonado, J.M. Reguera, Lucía Valiente de Santis, Antonio Plata, Juan Diego Ruiz Mesa, Beatriz Sobrino Diaz, Ignacio Márquez Gómez, Inés Pérez Camacho, Begoña Palop, Julián Torre-Cisneros, Ángela Cano, Azahara Frutos-Adame, Julia Guzmán-Puche, Irene Gracia-Ahufinger, Elena Pérez‐Nadales, Julián Torre-Giménez, Athina Pyrpasopoulou, Εlias Iosifidis, Elsa Chorafa, Biljana Carević, Snežana Jovanović, Ivana Radovanović, Sladjana Petrović, Slavica Cvetkovi, Lili Radulovic, Srdjan-Sanja Melentijevic, Nataša Miljković, Ana Perucica, Cenk Kıraklı, Can Biçmen, Güneş Şenol, Evelyn Shaw, Fé Tubau, Jordi Cámara, Victor Daniel Gumucio, George L. Daikos, John Deliolanis, Matthew E. Falagas, Vassiliki Pitiriga, Nikolaos A. Triarides, Efstathia Argiti, Nikolaos J. Legakis, Kyriakidou Margarita, Desirée Gijón-Cordero, Patricia Ruíz-Garbajosa, Amaya Suarez, Alessandro Bartoloni, Gian María Rossolini, Simin Aysel Florescu, Maria Nica, Șerban Benea, Daniela Tălăpan, Adriana Hristea, Sanja Prijić Maričić, Anita Jovetic, Marija Zivanovic Milenkovic, Ángel Asensio, Mireia Cantero Caballero, Lina M Parra Ramírez, Belen Ruiz-Antoran, Rocio Layunta-Acero, Belen Ruiz-Antoran, Volkan Korten, Hüseyin Bilgin, Ufuk Hasdemir, George Ν. Dalekos, Aggelos Stefos
Abstract
BACKGROUND: Carbapenem-resistant Enterobacterales (CRE) bloodstream infections (BSIs) are a major threat to patients. To date, data on risk factors have been limited, with low internal and external validity. In this multicentre study, risk factors for CRE BSI were determined by comparison with two control groups: patients with carbapenem-susceptible Enterobacterales (CSE) BSI, and patients without Enterobacterales infection (uninfected patients). METHODS: A multicentre, case-control-control study was nested in a European prospective cohort study on CRE (EURECA). CRE BSI:CSE BSI matching was 1:1, CRE BSI:Uninfected patients matching was 1:3, based on hospital, ward and length of stay. Conditional logistic regression was applied. RESULTS: From March 2016 to November 2018, 73 CRE BSIs, 73 CSE BSIs and 219 uninfected patients were included from 18 European hospitals. For CRE versus CSE BSI, previous CRE colonization/infection [incidence rate ratio (IRR) 7.32; 95% CI 1.65-32.38) increased the risk. For CRE versus uninfected controls, independent risk factors included: older age (IRR 1.03; 95% CI 1.01-1.06), patient referral (long-term care facility: IRR 7.19; 95% CI 1.51-34.24; acute care hospital: IRR 5.26; 95% CI 1.61-17.11), previous colonization/infection with other MDR organisms (MDROs) (IRR 9.71; 95% CI 2.33-40.56), haemodialysis (IRR 8.59; 95% CI 1.82-40.53), invasive procedures (IRR 5.66; 95% CI 2.11-15.16), and β-lactam/β-lactamase inhibitor combinations (IRR 3.92; 95% CI 1.68-9.13) or third/fourth generation cephalosporin (IRR 2.75; 95% CI 1.06-7.11) exposure within 3 months before enrolment. CONCLUSIONS: Evidence of previous CRE colonization/infection was a major risk factor for carbapenem resistance among Enterobacterales BSI. Compared with uninfected patients, evidence of previous MDRO colonization/infection and healthcare exposure were important risk factors for CRE BSI. Targeted screening, infection prevention and antimicrobial stewardship should focus on these high-risk patients.