Babcock, Hilary M

Burnham, Jason P

Kollef, Marin H

Kwon, Jennie H

Olsen, Margaret A

English

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Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2018Differences in mortality between infections due toextended-spectrum-beta-lactamase–producingKlebsiella pneumoniae and Escherichia coliJason P. BurnhamWashington University School of Medicine in St. LouisJennie H. KwonWashington University School of Medicine in St. LouisMargaret A. OlsenWashington University School of Medicine in St. LouisHilary M. BabcockWashington University School of Medicine in St. LouisMarin H. KollefWashington University School of Medicine in St. LouisFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationBurnham, Jason P.; Kwon, Jennie H.; Olsen, Margaret A.; Babcock, Hilary M.; and Kollef, Marin H., ,"Differences in mortality betweeninfections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniae and Escherichia coli." Infection Control &Hospital Epidemiology.39,09. 1138-1139. (2018).https://digitalcommons.wustl.edu/open_access_pubs/7123receiving piperacillin-tazobactam (12.3%) versus meropenem(3.7%).5 Such data should have been discussed. Likewise, noinformation is provided on treatment duration or dose, whichmay have varied between the 2 groups in the present study.1 Bothfactors play a role in the outcome of treatment, especially whenused against multidrug-resistant organisms.6Interestingly, we previously showed that BSI severity or mor-tality among spinal cord injury patients over 15 years was notrelated to the multidrug-resistant characteristics of the micro-organism.7 Although our sample size was small (n< 30), a closerlook at the outcome between ESBL-EC (n= 26) and ESBL-KP(n= 13) did not reveal any statistical difference in terms of mortalityrate (7.7% in each arm). Moreover, the mortality rates were similarfor other ESBL microorganisms (Enterobacter spp,Morganella spp,and Proteus spp (n=21)), ~ 9.5% (P= .99, data not shown).In fact, we believe that the findings of Scheuerman et al, whichshowed no impact of CTX-M isolates in comparison to otherESBL genotypes, might support the idea that the type of germdoes not play a major role. Indeed, mortality seems more relatedto patient comorbidities and severity of infection, as shown inTable 2 of the article,1 with significant discrepancies between the2 groups in terms of length of stay to bacteremia (P= .017),source of infection (P= .005), ICU ward admission (P< .001) andunderlying cardiovascular disease (P< .001). Moreover, in arabbit model of sepsis induced by a multidrug-resistant Klebsiellapneumoniae, Zhou et al8 showed that mortality was higher forthe rabbits infected by susceptible than those infected withmultidrug-resistant strains.Overall, the impact of ESBL-KP isolates on mortality ratemight have been overestimated, in the light of the severity of thepatient condition.Acknowledgments.Financial support. No financial support was provided relevant to this article.Potential conflicts of interest. All authors report no conflicts of interestrelevant to this article.References1. Scheuerman O, Schechner V, Carmeli Y, et al. Comparison of predictorsand mortality between bloodstream infections caused by ESBL-producingEscherichia coli and ESBL-producing Klebsiella pneumoniae. Infect ControlHosp Epidemiol 2018;39:660–667.2. Tabah A, Koulenti D, Laupland K, et al. Characteristics and determinantsof outcome of hospital-acquired bloodstream infections in intensive careunits: the EUROBACT International Cohort Study. Intensive Care Med2012;38:1930–1945.3. Adrie C, Garrouste-Orgeas M, Ibn Essaied W, et al. Attributable mortalityof ICU-acquired bloodstream infections: impact of the source, causativemicro-organism, resistance profile and antimicrobial therapy. J Infect2017;74:131–141.4. Artero A, Esparcia A, Eiros JM, Madrazo M, Alberola J, Nogueira JM.Effect of bacteremia in elderly patients with urinary tract infection. Am JMed Sci 2016;352:267–271.5. Harris PN, Peleg AY, Iredell J, et al. Meropenem versus piperacillin-tazobactam for definitive treatment of bloodstream infections due toceftriaxone non-susceptible Escherichia coli andKlebsiella spp (theMERINOtrial): study protocol for a randomised controlled trial. Trials 2015;16:24.6. Davido B, Bouchand F, Dinh A, et al. Reinforcement of an antimicrobialstewardship task force aims at a better use of antibiotics of last resort: theCOLITIFOS study. Int J Antimicrob Agents 2017;50:142–147.7. Saliba M, Saadeh D, Bouchand F, et al. Outcome of bloodstream infectionsamong spinal cord injury patients and impact of multidrug-resistantorganisms. Spinal Cord 2017;55(2). doi: 10.1038/sc.2016.176.8. Zhou Z, Ren J, Liu H, Gu G, Li J. Pandrug-resistant isolate of Klebsiellapneumoniae causes less damage than drug-susceptible isolates in arabbit model. Clin Invest Med 2011;34:E38–E44.Differences in mortality between infections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniae andEscherichia coliJason P. Burnham MD1, Jennie H. Kwon DO, MSCI1, Margaret A. Olsen PhD, MPH1, Hilary M. Babcock MD, MPH1and Marin H. Kollef MD21Division of Infectious Diseases Washington University School of Medicine, St Louis, Missouri; and 2Division of Pulmonary and Critical Care Medicine,Washington University School of Medicine, St Louis, Missouri.To the Editor—We read with interest the recent article byScheuerman et al,1 in which they found that patients withextended-spectrum-β-lactamase (ESBL) producing Klebsiellapneumoniae infections had higher 30-day mortality than patientswith ESBL producing Escherichia coli infections. We have recentlypublished on mortality, readmissions, recurrences, and the benefitof infectious diseases consultation for patients with variousmultidrug resistant organism infections.2,3 We included in ourstudy patients with various ESBL producing Enterobacteriaceaeinfections, among them K. pneumoniae and E. coli. Given therecent findings of Scheuerman et al, we conducted a retrospectiveevaluation to determine the association between ESBL producingorganism (K. pneumoniae or E. coli) and 30-day all-cause mor-tality at our institution.Cite this article: Burnham JP, et al. (2018). Differences in mortality betweeninfections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniaeand Escherichia coli. Infection Control & Hospital Epidemiology 2018, 39, 1138–1139. doi:10.1017/ice.2018.142Author for correspondence: Jason P. Burnham, MD, Division of Infectious DiseasesMedicine, Washington University School of Medicine, 4523 Clayton Avenue, CampusBox 8051, St Louis, MO 63110. E-mail: burnham@wustl.edu or Marin H. Kollef, MD,Division of Pulmonary and Critical Care, Washington University School of Medicine,4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110. E-mail: kollefm@wustl.edu© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.1138 Jason P. Burnham et alThis study was conducted at Barnes-Jewish Hospital, a 1,250-bed academic medical center in St Louis, Missouri. The studyperiod was January 1, 2006, to October 1, 2015. We includedpatients with positive sterile site and bronchial wash/bronch-oalveolar lavage cultures for ESBL-producing E. coli andK. pneumoniae. Sterile sites were defined as bloodstream; pleural,intra-abdominal, pericardial, cerebrospinal, and synovial fluids;bone marrow; and surgical specimens collected from lymphnodes, central nervous system, liver, spleen, kidney, pancreas,ovary, or vascular tissue. The presence of ESBL production wasassumed based on ceftriaxone, aztreonam, cefotaxime, or cefta-zidime nonsusceptibility.4 The Washington University School ofMedicine Institutional Review Board approved this study with awaiver of informed consent.The primary endpoint was 30-day all-cause mortality. Kaplan-Meier curves for 30-day all-cause mortality were generated tocompare organism type and significance determined using thelog-rank test. Escherichia coli was used as the reference group fordetermining the association between organism and mortality.Log-log survival plots were used to graphically test the propor-tional hazards assumption. Factors associated with mortality inbivariate analysis (P< .20) were entered into a multivariate Coxproportional hazards model to determine hazard ratios (HR) for30-day all-cause mortality. All analyses were conducted with SPSSversion 25 software (IBM, Armonk, NY).In total, 605 patients met the eligibility criteria: 543 withESBL E. coli and 62 with ESBL K. pneumoniae. Among patientswith ESBL E. coli, 96 (17.7%) died within 30 days compared to16 (25.8%) with ESBL K. pneumoniae. In Kaplan-Meier analysis,mortality was not significantly different between patients infec-ted with K. pneumoniae and E. coli ESBL organisms (P= 0.12).Variables retained in the final Cox proportional hazards model areshown in Table 1. Infection with ESBL-producing K. pneumoniaewas marginally associated with mortality in the final Cox propor-tional hazards model (hazard ratio [HR], 1.69; 95% confidenceinterval [CI], 0.97–2.92; P= .062). Because the number of patients inthe ESBL K. pneumoniae group was small, we performed a post-hocpower analysis and found that we had only 35.8% power to detect asignificant difference in mortality.Our results add to the body of literature on differences inmortality between ESBL-producing K. pneumoniae and E. coli.Despite the low power of our study, ESBL-producing K. pneu-moniae was associated with marginally increased risk of 30-daymortality. Our data are important to add to the literature on thissubject and could be combined with the data of Scheuerman et aland future studies in a meta-analysis to more definitively deter-mine the association between ESBL-producing organism type andmortality. In addition, as demonstrated in our previous study,infectious disease consultation was associated with reducedmortality for drug-resistant Enterobacteriaceae infections.Acknowledgments. The content is solely the responsibility of the authorsand does not necessarily represent the official view of the National Institutes ofHealth (NIH).Financial support. This work was supported by a grant from theWashington University Institute of Clinical and Translational Sciences(grant no. UL1TR000448) and by a subaward (no. KL2TR000450) fromthe National Center for Advancing Translational Sciences (NCATS) ofthe NIH.Potential conflicts of interest. Dr Kollef was supported by the Barnes-Jewish Hospital Foundation. All other authors report no conflicts of interestrelevant to this article.References1. Scheuerman O, Schechner V, Carmeli Y, et al. Comparison of predictorsand mortality between bloodstream infections caused by ESBL-producingEscherichia coli and ESBL-producing Klebsiella pneumoniae. Infect ControlHosp Epidemiol 2018;39:660–667.2. Burnham JP, Kwon JH, Olsen MA, Babcock HM, Kollef MH. Readmissionswith multidrug-resistant infection in patients with prior multidrug-resistant infection. Infect Control Hosp Epidemiol 2018;39:12–19.3. Burnham JP, Olsen MA, Stwalley D, Kwon JH, Babcock HM, Kollef MH.Infectious diseases consultation reduces 30-day and 1-year all-causemortality for multidrug-resistant organism infections. Open Forum InfectDis 2018;5(3):ofy026.4. Laboratory detection of extended-spectrum β-lactamases (ESBLs). Centersfor Disease Control and Prevention website. https://www.cdc.gov/hai/settings/lab/lab_esbl.html. Published 2010. Accessed May 30, 2018.Table 1. Factors Associated with 30-Day All-Cause Mortality in a Cox Propor-tional Hazards ModelaRisk FactorHazard Ratio(95% CI)PValueInfection with ESBL producing K. pneumoniae(reference group E. coli)1.69 (0.97–2.92) .062ComorbidityMetastatic cancer 3.20 (1.75–5.82) <.001HIV/AIDS 6.19 (2.38–15.1) <.001Cardiovascular disease 2.11 (1.38–3.46) .001Chronic respiratory failure 0.68 (0.42–1.08) .100Cirrhosis 4.95 (3.17–7.75) <.001Leukemia 2.42 (1.34–4.38) .003Solid organ cancer 2.00 (1.23–3.26) .005Index hospitalization characteristicsID consultation 0.37 (0.22–0.60) <.001Required ICU care during hospitalization 2.87 (1.77–4.64) <.001APACHE II score >21 2.29 (1.31–3.99) .003NOTE. HIV/AIDS, human immunodeficiency virus/acquired immunodeficiency syndrome;APACHE, Acute Physiology and Chronic Health Evaluation; CI, confidence interval; HR,hazard ratio; ICU, intensive care unit; ID, infectious diseases.aVariables not retained in final model included admitting service, sex, lymphoma, con-gestive heart failure, diabetes, solid organ transplant, bone marrow transplant, chronickidney disease, and end-stage renal disease.1139

Differences in mortality between infections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniae and Escherichia coli

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Differences in mortality between infections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniae and Escherichia coli

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