Carbapenem Resistance and Mortality in Institutionalized Elderly With Urinary Infection

Risk factors of carbapenem-resistant Klebsiella pneumoniae infection: a serious threat in ICUs

Background

Nosocomial infections caused by Carbapenem-resistant Klebsiella pneumoniae (CRKP) are increasing. Our aim in this study was to investigate the risk factors of CRKP infections.

Material/Methods

A retrospective cohort study was performed between 1 January and 31 December 2012 in ICU patients. Data was taken from the hospital infection control database for CRKP. The clinical samples collected from the patients were tested by an automatized system and disk diffusion. SPSS software v11.5 was used for statistical analysis.

Results

Totally, 105 Klebsiella pneumoniae isolates were found in 2012 and the carbapenem resistance rate was 48%. The first episode of infection was taken into risk factor analysis. Of the 98 patients, 61 (62.2%) were male and the mean and median ages were 30.4±29.8 and 25 (0–93). The length of stay was longer in the resistant group (p=0.026). Mortality was 48% in the whole group and similar between groups (p=0.533). There was a relationship between meropenem and third-generation cephalosporin use and resistance (OR 3.244 (1.193–8.819) and OR: 3.590 (1.056–12.209). The other risk factors in univariate analysis were: Immunosuppression OR: 2.186 (1.754–2.724), nasogastric catheter OR: 3.562 (1.317–9.634), peripheral arterial catheter OR: 2.545 (1.027–6.307), and being admitted to the neurosurgical unit OR: 4.324 (1.110–16.842).

The multivariate analysis showed use of third-generation cephalosporin OR: 4.699 (1.292–17.089), nasogastric catheter use OR: 3.983 (1.356–11.698), and being admitted to neurosurgical ICU OR: 4.603 (1.084–19.555) as independent risk factors.

Conclusions

Restriction of third-generation cephalosporin and carbapenem use and invasive procedures, along with infection control precautions and disinfection policies, may be effective in reducing the carbapenem resistance in ICUs.

Ethical dilemmas in antibiotic treatment: focus on the elderly

Maximal antibiotic treatment for all patients suspected of harbouring a bacterial infection is non-viable, because it will rapidly induce resistance and exhaust this finite resource. This raises two ethical dilemmas: the question of whether we are justified in increasing the danger to a present, named, patient so as to benefit future, unknown, patients; and whether we are allowed to do so without asking the present patient for consent. Although the considerations for healthy elderly patients are similar to younger adults, the answers are complex when addressing patients with dementia, severely reduced quality of life and at end of life. We argue that a public debate on the balance between benefit to a present patient versus harm to future patients should be conducted. Such a debate should include examinations of scenarios in which antibiotic treatment does not gain any benefit in a patient with infection: at the end of life; in situations in which resistance is such that empirical antibiotic treatment seldom matches the susceptibilities of the pathogen; and in patients with no quality of life. An explicit cost-benefit model, incorporating quality of life and risk of resistance, in computerized decision support might obviate a clinician's need to deal with these difficult issues at bedside.