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Anesi JA, Lautenbach E, Thom KA, Tamma PD, Blumberg EA, Alby K, Bilker WB, Werzen A, Ammazzalorso A, Tolomeo P, Omorogbe J, Pineles L, Han JH. Clinical Outcomes and Risk Factors for Carbapenem-resistant Enterobacterales Bloodstream Infection in Solid Organ Transplant Recipients. Transplantation 2023; 107:254-263. [PMID: 35856636 PMCID: PMC9772065 DOI: 10.1097/tp.0000000000004265] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The clinical outcomes associated with, and risk factors for, carbapenem-resistant Enterobacterales (CRE) bloodstream infections (BSIs) in solid organ transplant (SOT) recipients remain ill-defined. METHODS A multicenter retrospective cohort study was performed, including SOT recipients with an Enterobacterales BSI between 2005 and 2018. Exposed subjects were those with a CRE BSI. Unexposed subjects were those with a non-CRE BSI. A multivariable survival analysis was performed to determine the association between CRE BSI and risk of all-cause mortality within 60 d. Multivariable logistic regression analysis was performed to determine independent risk factors for CRE BSI. RESULTS Of 897 cases of Enterobacterales BSI in SOT recipients, 70 (8%) were due to CRE. On multivariable analysis, CRE BSI was associated with a significantly increased hazard of all-cause mortality (adjusted hazard ratio, 2.85; 95% confidence interval [CI], 1.68-4.84; P < 0.001). Independent risk factors for CRE BSI included prior CRE colonization or infection (adjusted odds ratio [aOR] 9.86; 95% CI, 4.88-19.93; P < 0.001)' liver transplantation (aOR, 2.64; 95% CI, 1.23-5.65; P = 0.012)' lung transplantation (aOR, 3.76; 95% CI, 1.40-10.09; P = 0.009)' and exposure to a third-generation cephalosporin (aOR, 2.21; 95% CI, 1.17-4.17; P = 0.015) or carbapenem (aOR, 2.80; 95% CI, 1.54-5.10; P = 0.001) in the prior 6 months. CONCLUSIONS CRE BSI is associated with significantly worse outcomes than more antibiotic-susceptible Enterobacterales BSI in SOT recipients.
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Affiliation(s)
- Judith A. Anesi
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kerri A. Thom
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland, Baltimore, MD
| | - Pranita D. Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily A. Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kevin Alby
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Warren B. Bilker
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alissa Werzen
- Division of Infectious Diseases, University of Maryland Medical Center, Baltimore, MD
| | - Alyssa Ammazzalorso
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacqueline Omorogbe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland, Baltimore, MD
| | - Jennifer H. Han
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Chan JL, Nazarian E, Musser KA, Snavely EA, Fung M, Doernberg SB, Pouch SM, Leekha S, Anesi JA, Kodiyanplakkal RP, Turbett SE, Walters MS, Epstein L. Prevalence of carbapenemase-producing organisms among hospitalized solid organ transplant recipients, five US hospitals, 2019-2020. Transpl Infect Dis 2022; 24:e13785. [PMID: 34989092 PMCID: PMC11318107 DOI: 10.1111/tid.13785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Passive reporting to the Centers for Disease Control and Prevention has identified carbapenemase-producing organisms (CPOs) among solid organ transplant (SOT) recipients, potentially representing an emerging source of spread. We analyzed CPO prevalence in wards where SOT recipients receive inpatient care to inform public health action to prevent transmission. METHODS From September 2019 to June 2020, five US hospitals conducted consecutive point prevalence surveys (PPS) of all consenting patients admitted to transplant units, regardless of transplant status. We used the Cepheid Xpert Carba-R assay to identify carbapenemase genes (blaKPC , blaNDM , blaVIM , blaIMP , blaOXA-48 ) from rectal swabs. Laboratory-developed molecular tests were used to retrospectively test for a wider range of blaIMP and blaOXA variants. RESULTS In total, 154 patients were screened and 92 (60%) were SOT recipients. CPOs were detected among 7 (8%) SOT recipients, from two of five screened hospitals: four blaKPC , one blaNDM , and two blaOXA-23 . CPOs were detected in two (3%) of 62 non-transplant patients. In three of five participating hospitals, CPOs were not identified among any patients admitted to transplant units. CONCLUSIONS Longitudinal surveillance in transplant units, as well as PPS in areas with diverse CPO epidemiology, may inform the utility of routine screening in SOT units to prevent the spread of CPOs.
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Affiliation(s)
- June L. Chan
- Wadsworth Center, New York State Department of Health, Albany, NY
| | | | | | - Emily A. Snavely
- Wadsworth Center, New York State Department of Health, Albany, NY
| | - Monica Fung
- University of California San Francisco, San Francisco, CA
| | | | | | - Surbhi Leekha
- University of Maryland Medical Center, Baltimore, MD
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Wu D, Chen C, Liu T, Wan Q. Risk Factors for Acquisition of Carbapenem-Resistant Klebsiella pneumoniae and Mortality Among Abdominal Solid Organ Transplant Recipients with K. pneumoniae Infections. Med Sci Monit 2020; 26:e922996. [PMID: 32807765 PMCID: PMC7458125 DOI: 10.12659/msm.922996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background For abdominal solid organ transplant (ASOT) recipients, infection with Klebsiella pneumoniae, particularly carbapenem-resistant K. pneumoniae (CRKP), can be life-threatening. The aims of this study were to characterize the risk factors associated with acquisition of CRKP and 90-day crude mortality among patients. Material/Methods In our cohort study, we retrospectively reviewed 68 K. pneumoniae-infected transplant recipients, studied their demographics, clinical manifestations, microbiology, and outcomes, and determined the risk factors associated with the occurrence of CRKP and crude mortality due to K. pneumoniae infections. Results Sixty-eight ASOT recipients (5.4%) experienced 78 episodes of K. pneumoniae infection. Among these, 20 patients (29.4%) died. The independent risk factors associated with mortality were multiple infected organs or sites (odds ratio=22.034, 95% confidence intervals=4.348–111.653, P=0.001) and septic shock (odds ratio=27.090, 95% confidence intervals=1.841–398.512, P=0.016). Risk factors associated with acquisition of CRKP were multiple infected organs or sites (odds ratio=3.056, 95% confidence intervals=1.091–8.556, P=0.033). Conclusions K. pneumoniae infections, especially CRKP, frequently occurred among ASOT recipients, with a high mortality rate. Multiple infected organs or sites and septic shock were predictors of crude mortality caused by K. pneumoniae infections, while CRKP infections were associated with multiple infected organs or sites. Greater efforts are needed towards improved antibiotic administration, early diagnosis and precise treatment, recognition of septic shock, and reduced length of hospitalization.
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Affiliation(s)
- Di Wu
- Department of Transplantation, Xiangya Third Hospital of Central South University, Changsha, Hunan, China (mainland)
| | - Chunmei Chen
- Department of Pediatrics, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, Guangdong, China (mainland)
| | - Taohua Liu
- Xiangya Medical School, Central South University, Changsha, Hunan, China (mainland)
| | - Qiquan Wan
- Department of Transplantation, Xiangya Third Hospital of Central South University, Changsha, Hunan, China (mainland)
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Smibert O, Satlin MJ, Nellore A, Peleg AY. Carbapenem-Resistant Enterobacteriaceae in Solid Organ Transplantation: Management Principles. Curr Infect Dis Rep 2019; 21:26. [PMID: 31183574 DOI: 10.1007/s11908-019-0679-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as a worldwide problem. Given their degree of immunosuppression and the level of contact with the healthcare system, solid organ transplant (SOT) recipients are at a disproportionately higher risk of acquisition, colonization, and infection with CRE, and outcomes from infection tend to be worse compared to non-transplant patients. Therapeutic options are limited for CRE infections although several newer agents have recently been approved for use. How well these agents perform in the setting of immunosuppression and SOT is unclear. We sought to review the epidemiology of CRE in SOT and the management principles. RECENT FINDINGS CRE infections are becoming an increasing problem in SOT, and donor-derived infections present a challenge in the peri-transplant period. Newer treatments for CRE are emerging that are less toxic and potentially more effective than prior CRE-active agents, but supportive clinical data are limited. Newer beta-lactamase inhibitors have good activity against KPC carbapenemases, but they lack activity against metallo-beta-lactamases (e.g., NDM). Promising data is emerging with newer agents that have activity against most carbapenemases, but, again, clinical data is needed. Combination therapy in addition to optimal pharmacokinetic and pharmacodynamics may go some way to improve outcomes against these difficult-to-treat organisms. Other novel therapies that prevent the emergence of resistance (oral beta-lactamase inhibitors) and eradication of resistant Gram-negative colonization (fecal microbiota transplant) may eventually become part of a bundle approach to reduce CRE infections in the future. As in non-transplant patients, CRE infections in the transplant setting are challenging to treat and prevent. Infection prevention and control remains crucial to prevent widespread dissemination, and unique challenges exist with donor-derived CRE and how best to manage recipients in the peri-transplant period. Newer treatments are now in early-phase clinical studies, and in vitro activity data are supportive for several agents providing hope for improved outcomes with these typically difficult-to-treat and highly morbid infections in transplant recipients.
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Affiliation(s)
- Olivia Smibert
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia.,Transplant Infectious Disease and Compromised Host Program, Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Satlin
- Division of Infectious Diseases, Weill Cornell Medicine, 1300 York Avenue, New York, NY, USA
| | - Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia. .,Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia.
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