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      Risk factor for intestinal carriage of carbapenem-resistant Acinetobacter baumannii and the impact on subsequent infection among patients in an intensive care unit: an observational study

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          Abstract

          Objectives

          To assess the incidence and the impact of carbapenem-resistant Acinetobacter baumannii (CRAB) intestinal carriage on subsequent CRAB infection and to study risk factors of acquiring CRAB intestinal carriage among patients in intensive care unit (ICU).

          Design

          Observational study including a case–control study and a retrospective cohort study.

          Setting

          A 50-bed general ICU of a university hospital, China.

          Methods

          From May 2017 to April 2018, an observational study was conducted in a 50-bed general ICU of a university hospital in China. Rectal swabs were collected from ICU patients on admission and thereafter weekly. A case–control study was performed to analyse risk factors of the acquisition of CRAB intestinal carriage in ICU using multiple logistic regression. A retrospective cohort study was performed to address whether intestinal CRAB carriage could lead to an increased likelihood of subsequent CRAB infection using subdistribution hazard model regarding death in the ICU as a competing risk event.

          Results

          CRAB intestinal carriage was detected in 6.87% (66/961; 95% CI 5.27% to 8.47%) of patients on ICU admission, whereas 11.97% (115/961; 95% CI 9.91% to 14.02%) of patients acquired CRAB intestinal carriage during the ICU stay. Pancreatitis (OR 2.16, 95% CI 1.28 to 3.67), haematological disease (OR 2.26, 95% CI 1.42 to 3.58), gastric tube feeding (OR 3.35, 95% CI 2.03 to 5.51) and use of carbapenems (OR 1.84, 95% CI 1.11 to 3.07) were independent risk factors for acquiring CRAB intestinal carriage. The incidence of subsequent CRAB infection was 2.24-fold in patients with CRAB intestinal carriage compared with that in patients without (95% CI 1.48 to 3.39, p<0.001).

          Conclusion

          More patients acquired CRAB intestinal carriage during their ICU stay than had on admission. Severity of illness, acute pancreatitis, tube feeding and use of carbapenems were independent risk factors of acquisition of CRAB intestinal carriage. Patients with CRAB intestinal carriage are more likely to develop CRAB infection.

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          Most cited references21

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          Regression modeling of competing risk using R: an in depth guide for clinicians.

          We describe how to conduct a regression analysis for competing risks data. The use of an add-on package for the R statistical software is described, which allows for the estimation of the semiparametric proportional hazards model for the subdistribution of a competing risk analysis as proposed by Fine and Gray. J Am Stat Assoc 1999; 94: 496-509.
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            Risk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review.

            Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as important health care-associated pathogens. Colonization precedes infection but the risk of developing infection amongst those colonized with CRE is not clear.
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              Carbapenem-resistant Enterobacteriaceae colonization (CRE) and subsequent risk of infection and 90-day mortality in critically ill patients, an observational study

              Background Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as an urgent public health threat. Intestinal colonization with CRE has been identified as a risk factor for the development of systemic CRE infection, but has not been compared to colonization with third and/or fourth generation cephalosporin-resistant (Ceph-R) Enterobacteriaceae. Moreover, the risk conferred by colonization on adverse outcomes is less clear, particularly in critically ill patients admitted to the intensive care unit (ICU). Methods We carried out a cohort study of consecutive adult patients screened for rectal colonization with CRE or Ceph-R upon ICU entry between April and July 2013. We identified clinical variables and assessed the relationship between CRE or Ceph-R colonization and subsequent systemic CRE infection within 30 days (primary outcome) and all-cause mortality within 90 days (secondary outcome). Results Among 338 ICU patients, 94 (28%) were colonized with either Ceph-R or CRE. 26 patients developed CRE infection within 30 days of swab collection; 47% (N = 17/36) of CRE-colonized and 3% (N = 2/58) of Ceph-R colonized patients. 36% (N = 13/36) of CRE-colonized patients died within 90 days compared to 31% (N = 18/58) of Ceph-R-colonized and 15% (N = 37/244) of non-colonized patients. In a multivariable analysis, CRE colonization independently predicted development of a systemic CRE infection at 30 days (aOR 10.8, 95% CI2.8–41.9, p = 0.0006); Ceph-R colonization did not (aOR 0.5, 95% CI0.1–3.3, p = 0.5). CRE colonization was associated with increased 90-day mortality in a univariable analysis (p-value 0.001), in a multivariable model, previous hospitalization and medical ICU admission were independent predictors of 90-day mortality whereas CRE colonization approached significance (aOR 2.3, 95% CI1.0–5.3, p = 0.056). Conclusions Our study highlights the increased risk of CRE infection and mortality in patients with CRE colonization at the time of ICU admission. Future studies are needed to assess how CRE colonization can guide empiric antibiotic choices and to develop novel decolonization strategies.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2020
                9 September 2020
                : 10
                : 9
                Affiliations
                [1 ]departmentDepartment of Infection Control , West China Hospital, Sichuan University , Chengdu, Sichuan, China
                [2 ]departmentDepartment of Infection Control , The First Affiliated Hospital, Zhengzhou University , Zhengzhou, Henan, China
                [3 ]departmentIntensive Care Unit , West China Hospital, Sichuan University , Chengdu, Sichuan, China
                [4 ]departmentDepartment of Laboratory Medicine , West China Hospital, Sichuan University , Chengdu, Sichuan, China
                [5 ]departmentCenter of Infectious Disease , West China Hospital, Sichuan University , Chengdu, Sichuan, China
                Author notes
                [Correspondence to ] Professor Zhiyong Zong; zongzhiyong@ 123456gmail.com ; Dr Chuanmin Tao; taocm@ 123456scu.edu.cn
                Article
                bmjopen-2019-035893
                10.1136/bmjopen-2019-035893
                7482480
                368a94f3-ee05-4eb2-9821-ff775bae09ec
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                Product
                Funding
                Funded by: West China Hospital of Sichuan University;
                Award ID: 1.3.5 project for disciplines of excellence, proje
                Funded by: the Newton Advanced Fellowship, Royal Society, UK;
                Award ID: NA150363
                Funded by: FundRef http://dx.doi.org/10.13039/501100001809, National Natural Science Foundation of China;
                Award ID: no. 81772233, 81661130159 and 81861138055
                Categories
                Epidemiology
                1506
                1692
                Original research
                Custom metadata
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                Medicine
                epidemiology,adult intensive & critical care,infection control
                Medicine
                epidemiology, adult intensive & critical care, infection control

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