Risk factors of cephalosporin-resistant Enterobacter cloacae bacteremia and prognosis of patients with Enterobacter cloacae bacteremia with emphasis on antimicrobial regimen
Date Issued
2009
Date
2009
Author(s)
Kuo, Li-Fen
Abstract
Objectives:he goal of this study is to evaluate the 30-day mortality of Enterobacter cloacae bacteremia and its prognosis factors. The impact of adequate therapy on clinical outcome, and risk factors of third generation cephalosporin-resistant E. cloacae bacteremia were also assessed.tudy design and study populations: retrospective cohort analysis was performed by charts reviewing for all adult patients hospitalized at the National Taiwan University Hospital (NTUH), a medical center in Northern Taiwan, with E. cloacae bloodstream infection between January 1, 2007 and December 31, 2007. esearch methods:ata were collected from medical records and computerized databases and documented in the customized case report form. The data retrieved for each patient included patients’profile, underlying diseases, comorbidities and other potential risk factors for infection; previous hospitalization, previous history of E. cloacae bloodstream infection or colonization history, antibiotics exposure before bacteremia onset, clinical presentation when bacteremia onset, antibiotics regimens during treatment period, and clinical response to antibiotic treatment. The primary endpoint was 30 day all-cause mortality. Risk factors of third generation cephalosporin- resistant E. cloacae were also analysed.he statistical methods used included: Chi-Square test, Mann-Whitney U test , T-test, Fisher’s exact test. Risk factors and clinical outcomes were examed using univariate analysis and multivariate logistic regression analysis. Survival curves shown by Kaplan-Meier method were analyzed with Log-rank test.esults:ne hundred sixty-eight patients with E. cloacae bacteremia were enrolled in the study, 107 (63.7%) were monomicrobial infections and 61 (36.3%) were polymicrobial infections. One hundred fifty episodes (89.3%) were classified as nosocomial infections. The age of patients ranged from 21 to 89 years (median, 62.5 years). The proportion of male to female patients was approximately 1.25:1.0 (94 v.s 74). Length of stay in hospitals ranged from 1 to 2695 days (median, 37.5 days).harslon’s comorbidity score ranged from 0 to 11 (median, 3). The most common underlying diseases was cardiovascular diseases (93 episodes, 55.4%), neoplastic diseases (81, 48.21%), renal diseases (56, 33.3%) and GI diseases (55, 32.7%). Intra-abdominal (40.5%) site was the major source of bacteremia of the patients belonged to primary bacteremia.itt bacteremia score ranged from 0 to 14 (median, 2) and the clinical presentation at bacteremia onset was sepsis in 89 episodes (53%). Time to receipt effective antibiotic therapy was from 0 to 257.75 hours (median, 20.5 hours).he 30 day all-cause mortality rate was 26.2% (44/168) and was 23.4% (25/107) in patients with monomicrobial bacteremia. There was no significant differences about mortality between monomicrobial and polymicrobial infections.ultivariate analysis showed that length of stay before bacteremia (odds ratio(OR), 1.02; 95% confidence interval ﹝CI﹞, 1.01-1.04; p=0.008), respiratory diseases (OR, 4.99; 95% CI, 1.65-15.18; p=0.005), previous use β-lactam/β-lactamase inhibitors (OR, 3.17; 95% CI, 1.31-7.71; p=0.01), third-generation cephalosporins (OR, 18.53; 95% CI, 4.91-69.96; p=<0.0001）or fourth–generation cephalosporins (OR, 7.96; 95% CI, 1.35-46.84; p=0.02）used prior to E. cloacae bacteremia were significantly associated with cephalosporin-resistant E. cloacae bacteremia. Among patients with monomicrobial infection, respiratory diseases (OR, 9.71; 95% CI, 2.62-36.02; p=0.0007), indwelling catheter (OR, 4.12; 95% CI, 1.19-14.29; p=0.026) or previous usage of third-generation cephalsoporins or fourth-generation cephalosporins (OR, 15.13; 95% CI, 4.32-53.06; p<0.0001) were associated with cephalosporin-resistant E. cloacae bacteremia.mong patients with E. cloacae bacteremia, those with nosocomial infection (OR, 12.64; 95% CI, 1.07-148.83; p=0.04) or higher Charslon’s comorbidity score (OR, 1.18; 95% CI, 1.002-1.39; p=0.05) or higher Pitt bacteremia score (OR, 1.43; 95% CI, 1.22-1.69; p=<0.0001) or respiratory tract infection source (OR, 3.98; 95% CI, 1.09-14.54; p=0.04) or intra-abdominal infection source (OR, 4.27; 95% CI, 1.65-11.03; p=0.003) had an increased risk of mortality. Among monomicrobial infections, those with malignancy (OR, 6.21; 95% CI, 1.92-20.16; p=0.002) or higher Pitt bacteremia score (OR, 1.48; 95% CI, 1.21-1.80; p=0.0001) had an increased risk of mortality. Resistance of E. cloacae, adequacy of antimicrobial treatment, and delayed adequate treatment were not associated with mortality.onclusions:osocomial infection, Charslon’s comorbidity score, Pitt bacteremia score, respiratory tract infection source and intra-abdominal infection source were found to be associated with poor prognosis by multivariate analysis in patients with E. cloacae bacteremia.isk factors of third-generation cephalosporin-resistant E. cloacae bacteremia were associated with length of stay before bacteremia onset, respiratory diseases, and previous use of any β-lactam/β-lactamase inhibitors, third- or fourth-generation cephalosporins.
Subjects
Enterobacter cloacae
bacteremia
risk factors
resistance
mortality
adequate antaimicrobial therapy
SDGs
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