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Kreitmann L, Vasseur M, Jermoumi S, Perche J, Richard JC, Wallet F, Chabani M, Nourry E, Garçon P, Zerbib Y, Van Grunderbeeck N, Vinsonneau C, Preda C, Labreuche J, Nseir S. Relationship between immunosuppression and intensive care unit-acquired colonization and infection related to multidrug-resistant bacteria: a prospective multicenter cohort study. Intensive Care Med 2023; 49:154-165. [PMID: 36592202 DOI: 10.1007/s00134-022-06954-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/05/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE The impact of immunosuppression on intensive care unit (ICU)-acquired colonization and infection related to multidrug-resistant (MDR) bacteria (ICU-MDR-col and ICU-MDR-inf, respectively) is unknown. METHODS We carried out an observational prospective cohort study in 8 ICUs in France (all with single-bed rooms and similar organizational characteristics). All consecutive patients with an ICU stay > 48 h were included, regardless of immune status, and followed for 28 days. Patients underwent systematic screening for colonization with MDR bacteria upon admission and every week subsequently. Immunosuppression was defined as active cancer or hematologic malignancy, neutropenia, solid-organ transplant, use of steroids or immunosuppressive drugs, human immunodeficiency virus infection and genetic. The primary endpoint was the incidence rate of a composite outcome including ICU-MDR-col and/or ICU-MDR-inf. RESULTS 750 patients (65.9% males, median age 65 years) were included, among whom 264 (35.2%) were immunocompromised. Reasons for ICU admission, severity scores and exposure to invasive devices and antibiotics during ICU stay were comparable between groups. After adjustment for center and pre-specified baseline confounders, immunocompromised patients had a lower incidence rate of ICU-MDR-col and/or ICU-MDR-inf (adjusted incidence ratio 0.68, 95% CI 0.52-0.91). When considered separately, the difference was significant for ICU-MDR-col, but not for ICU-MDR-inf. The distribution of MDR bacteria was comparable between groups, with a majority of Enterobacteriacae resistant to third-generation cephalosporins (~ 74%). CONCLUSION Immunocompromised patients had a significantly lower incidence rate of a composite outcome including ICU-MDR-col and/or ICU-MDR-inf. This finding points to the role of contact precautions and isolation measures, and could have important implications on antibiotic stewardship in this population.
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Affiliation(s)
- Louis Kreitmann
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France.,Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Margot Vasseur
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France
| | - Sonia Jermoumi
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France
| | | | - Jean-Christophe Richard
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital de la Croix Rousse, 69004, Lyon, France
| | - Florent Wallet
- Service de Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, 69637, Pierre Bénite, France.,Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, ENS Lyon, Claude Bernard Lyon University, Villeurbanne, France
| | - Myriam Chabani
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Emilie Nourry
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Pierre Garçon
- Réanimation, Grand Hôpital de l'Est Francilien, Site de Marne-La-Vallée, Jossigny, France
| | - Yoann Zerbib
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | | | | | - Cristian Preda
- Department of Medical Research, Biostatistics, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lille, France.,Laboratoire Paul Painlevé, Université de Lille, CNRS UMR 8524, 59000, Lille, France
| | | | - Saad Nseir
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France. .,Inserm U1285, Université de Lille, CNRS, UMR 8576-UGSF, 59000, Lille, France.
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Kernéis S, Lucet JC, Santoro A, Meschiari M. Individual and collective impact of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in patients admitted to the ICU. J Antimicrob Chemother 2021; 76:i19-i26. [PMID: 33534878 DOI: 10.1093/jac/dkaa494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
KPC-producing Klebsiella pneumoniae (KPC-Kp) raises major concerns in the context of intensive care, owing to limited treatment options and the ability to cause outbreaks in this specific setting. The objectives of this review are to give an overview of the burden of KPC-Kp in ICU patients and to discuss methodological issues and limitations regarding the quality of data available. Robust and reliable assessment of the KPC-Kp impact in the ICU should take into consideration not only characteristics of the individuals, but also of the health systems including length of stay, costs and hospital organization issues. Estimates of mortality reported in the current literature are weakened by the poor quality of adjustment for age-specific risks, co-morbidities, and appropriateness of therapy. All these confounding factors should be taken into account in models, with consideration of control groups and competing risks that is currently lacking in the published literature. Since development of antibiotic resistance is an unstoppable phenomenon and economic and human resources are facing progressive limitations due to budget constraints, cost-saving strategies targeted to avoid ICU closure, temporary limitation of admissions or delayed hospital discharge are necessary. The early identification of KPC-Kp-colonized patients through active screening strategies is likely to be the cornerstone of such a cost-saving strategy. However, there are still many open issues concerning which of these strategies are the most effective. Owing to extreme heterogeneity and several methodological flaws in current publications, future studies investigating the long-term sequelae and economic impact of KPC-Kp in the ICU are urgently needed.
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Affiliation(s)
- Solen Kernéis
- Université de Paris, INSERM, IAME, F-75018, Paris, France.,Equipe de Prévention du Risque Infectieux, APHP, Hôpital Bichat, F-75018, Paris, France
| | - Jean Christophe Lucet
- Université de Paris, INSERM, IAME, F-75018, Paris, France.,Equipe de Prévention du Risque Infectieux, APHP, Hôpital Bichat, F-75018, Paris, France
| | - Antonella Santoro
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
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