Treatment and Outcomes of Infections Caused by Diverse Carbapenemase-Producing Carbapenem-Resistant Enterobacterales.
Treatment and Outcomes of Infections Caused by Diverse Carbapenemase-Producing Carbapenem-Resistant Enterobacterales.
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DOI：
10.3389/fcimb.2020.579462
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发表时间：
2020
影响因子：
5.7
通讯作者：
Kwa ALH
中科院分区：
文献类型：
--
作者：
Lim FK;Liew YX;Cai Y;Lee W;Teo JQM;Lay WQ;Chung J;Kwa ALH
工作背景：新加坡出现了多种序列型（ST）和各种产碳青霉烯酶的碳青霉烯类耐药肠球菌（CP-CRE）感染，使治疗策略复杂化。我们的目的是根据其碳青霉烯酶类型描述这些CP-CRE感染和临床结局，并确定可转化为临床实践的死亡率预测因子的层次结构。方法：2013年至2016年期间，在新加坡总医院确定了具有临床意义的CP-CRE感染。回顾过去，所有临床相关数据均来自医院的电子病历。进行单因素分析。为了进一步探讨CP-CRE患者不同亚组中变量与死亡率之间的关系，我们使用R.结果：155例患者纳入研究。其中，169个独特的CP-CRE被分离。30天全因住院死亡率为35.5%（n = 55）。各种碳青霉烯酶之间的疾病严重程度或患者表现出的任何临床结局均无差异。根节点始于急性身体和慢性健康评估（APACHEII）评分≥ 15（n = 98;死亡风险= 52.0%）和<15（n = 57;死亡风险= 9.0%）的患者。APACHEII评分≥ 15的患者根据是否进行细菌根除（n = 27;死亡风险= 23.0%）和未进行细菌根除（n = 71，死亡风险= 62.0%）进一步分类。在没有细菌根除的情况下，不存在（n = 54）和存在（n = 17）活性源控制分别产生70.0%和35.0%的死亡风险。在没有主动源控制的情况下，未接受明确联合治疗的患者（n = 36，死亡风险= 83.0%）的死亡风险高于接受联合治疗的患者（n = 18，死亡风险= 47.0%）。总体而言，分类树的受试者工作特征曲线下面积为0.92，灵敏度为0.87，特异性为0.91。结论：不同的治疗策略观察到不同的死亡风险。有效的源头控制和微生物根除与较低的死亡率相关，但与积极的经验性治疗CP-CRE感染无关。当源头控制是不可能的，明确的抗生素组合似乎与死亡率降低。
Background: Diverse sequence types (ST) and various carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE) infections, which complicate treatment strategies, have emerged in Singapore. We aim to describe these CP-CRE infections and clinical outcomes according to their carbapenemase types and determine the hierarchy of predictors for mortality that are translatable to clinical practice. Methods: Clinically significant CP-CRE infections were identified in Singapore General Hospital between 2013 and 2016. Retrospectively, all clinically relevant data were retrieved from electronic medical records from the hospital. Univariate analysis was performed. To further explore the relationship between the variables and mortality in different subsets of patients with CP-CRE, we conducted recursive partitioning analysis on all study variables using the “rpart” package in R. Results: One hundred and fifty five patients were included in the study. Among them, 169 unique CP-CRE were isolated. Thirty-day all-cause in-hospital mortality was 35.5% (n = 55). There was no difference in the severity of illness, or any clinical outcomes exhibited by patients between the various carbapenemases. Root node began with patients with Acute Physical and Chronic Health Evaluation (APACHEII) score ≥ 15 (n = 98; mortality risk = 52.0%) and <15 (n = 57; mortality risk = 9.0%). Patients with APACHEII score ≥ 15 are further classified based on presence (n = 27; mortality risk = 23.0%) and absence (n = 71, mortality risk = 62.0%) of bacterial eradication. Without bacterial eradication, absence (n = 54) and presence (n = 17) of active source control yielded 70.0 and 35.0% mortality risk, respectively. Without active source control, the mortality risk was higher for the patients with non-receipt of definite combination therapy (n = 36, mortality risk = 83.0%) when compared to those who received (n = 18, mortality risk = 47.0%). Overall, the classification tree has an area under receiver operating characteristic curve of 0.92, with a sensitivity of 0.87 and specificity of 0.91. Conclusion: Different mortality risks were observed with different treatment strategies. Effective source control and microbial eradication were associated with a lower mortality rate but not active empiric therapy for CP-CRE infection. When source control was impossible, definitive antibiotic combination appeared to be associated with a reduction in mortality.