Brega, C

Coppo, E

Del Bono, V

Di Biase, C

Giacobbe, Dr

Marchese, A

Olivieri, Gm

Salsano, A

Santini, F.

Sportelli, E

Viscoli, C

English

Salsano A

Giacobbe DR

Sportelli E

Olivieri GM

Brega C

Di Biase C

Coppo E

Marchese A

Del Bono V

Viscoli C

Santini F.

Archivio istituzionale della ricerca - Università di Genova

Risk factors for infections due to carbapenem-resistant Klebsiella pneumoniae after cardiac surgeryBackground• The number of hospital outbreaks caused by carbapenem-resistant Klebsiella pneumoniae (CR-Kp) has rapidly increased in recent years, and CR-Kp is now considered endemic in several countries, including Italy • Mortality associated with CR-Kp infections has been reported to be as high as 40-60%• Patients undergoing major surgery are at increased risk of developing CR-Kpinfections in comparison with other patient populations. In this regard, identifying risk factors for CR-Kp infection might be crucial to prevent the disease and reduce morbidity and mortality in the postoperative period.• Aim of the present study was to assess risk factors for CR-Kp infections after cardiac surgeryPatients• The study was conducted at the IRCCS AOU San Martino-IST teaching Hospital, University of Genoa, Genoa, Italy.• All 553 patients who underwent open heart surgery from January 2014 to December 2014, were included in the study. Methods 1• Single-center retrospective study • The primary study endpoint was postoperative CR-Kp infection. • CR-Kp infection was defined and classified according to the Centers for Disease Control and Prevention (CDC) criteria. Only the first CR-Kp infection episode after cardiac surgery was considered for the analysis. Identification of CR-Kp from rectal swab in absence of signs and symptoms of infection was defined as CR-Kpcolonization. • For all patients, routine surveillance rectal swabbing was performed at standard points in time: (i) before surgery; (ii) the first day after surgery and every seven days thereafter until discharge. According to the time of the first positive culture, isolation of CR-Kp from rectal swab was categorized as pre-surgery (i) or post-surgery (ii) CR-Kp colonization. • Potential predictors of CR-Kp infection were compared between patients who developed CR-Kp infection and those who did not, by means of the χ² test, the Fisher exact test, or the Mann-Whitney U test, as appropriate.Methods 2• To assess the independent role of variables, a multivariate Cox regression was carried out using a stepwise backward procedure, after having verified proportional hazards. All variables associated with CR- Kp infection in the univariate analysis (p < 0.10) were included in the model. • For the purpose of the analysis, CR-Kp colonization was included in the model as a time-dependent covariate, according to the time of the first positive rectal swab. • A secondary endpoint was the occurrence of postoperative mortality within six-months after surgery through non-adjusted survival estimates calculated with the Kaplan-Meier product-limit method. Then, to reduce the possible confounding effect of patients’ characteristics, survival curves were adjusted for age, sex, comorbiditiesResults 1• Among 553 patients undergoing open heart surgery at our hospital, 32 developed CR-Kp infections (6%). • In the final multivariate model, CR-Kp colonization, chronic obstructive pulmonary disease, postoperative stroke,  postoperative mechanical ventilation >48, cardiopulmonary bypass time >120 min, and female sex were significantly associated with the risk of developing CR-Kp infection. Variable Hazard Ratio (95% CI) pCR-Kp colonization (time-dep covariate) 577.6 (71.9-4638.6) <0.001COPD 11.3 (3.9-32.4) <0.001Postoperative stroke 7.0 (2.3-21.7) <0.001Postoperative MV > 48 h 6.5 (2.4-17.2) <0.001CPB time > 120 min 2.6 (1.1-6.0) 0.023Female sex 2.3 (1.1-5.0) 0.034Non-adjusted survival curve (KM method) Survival curve adjusted for age, sex, comorbidities(on the basis of Coxʹs proportional hazards regression)Results 2• A reduced survival was observed in patients who developed CR-Kpinfections in comparison with those who did not (log-rank test, p<0.001).Conclusion• In our cohort CR-Kp colonization was the strongest predictor of CR-Kpinfection after cardiac surgery, with most colonization and infections occurring in the early postoperative period. • CR-Kp infection after cardiac surgery significantly affected survival. • Because of the dramatic shortage of dependable therapeutic options, maximized preventive efforts might be the most effective strategy to reduce the unfavorable impact of CR-Kp on postoperative morbidity and mortality, and to control dissemination.

Risk factors for infections due to carbapenem-resistant Klebsiella pneumoniae after cardiac surgery

https://iris.unige.it/bitstream/11567/941262/1/SICCH%202016.pdf

Risk factors for infections due to carbapenem-resistant Klebsiella pneumoniae after cardiac surgery

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Archivio istituzionale della ricerca - Università di Genova