Factors Affecting Clinical Outcomes of Carbapenem-Resistant Enterobacteriaceae and Carbapenem-Susceptible Enterobacteriaceae Infections

Factors influencing decision making and antibiotic prescribing patterns for the treatment of carbapenem-resistant Enterobacteriaceae (CRE) among non-infectious physicians in Thailand: a qualitative study

The treatment of carbapenem-resistant Enterobacteriaceae (CRE) is diverse in each region due to the difference in local resistant patterns of CRE. We aimed to explore how physicians in Thailand decide on selection options for treating CRE infections. In this study, 25 physicians who were not infectious disease (ID) specialists participated in this semi-structured in-depth interview. We found that they, in general, did not provide empiric antibiotics for the treatment of CRE. However, some patients, e.g., those with prior carbapenems exposure may have brought CRE to physicians' attention. ID specialists played critical roles in both empiric and specific CRE treatment. There were multiple scenarios when CRE management deviated from recommendations, especially when physicians perceived that the evidence that supported the recommendations was weak. Several supportive factors, challenges, and improvements were also suggested. In conclusion, ID specialists, adequate information, and consistent implementation of infectious control policy are crucial to the treatment and prevention of CRE infection.

The burden of carbapenem-resistant Enterobacterales infection in a large Thai tertiary care hospital

Background: Carbapenem-resistant Enterobacterales (CRE) are resistant to several other classes of antimicrobials, reducing treatment options and increasing mortality. We studied the clinical characteristics and burden of hospitalized adult patients with CRE infections in a setting where treatment options are limited.

Methods: A retrospective cohort study included adult inpatients between January 2015–December 2019 at Siriraj Hospital in Bangkok, Thailand. Clinical and microbiological data were reviewed.

Results: Of 420 patients with CRE infections, the mean age was 65.00 ± 18.89 years, 192 (45.72%) were male, and 112 (26.90%) were critically ill. Three hundred and eighty (90.48%) had Klebsiella pneumoniae, and 40 (9.52%) had Escherichia coli infections. The mean APACHE II score was 14.27 ± 6.36. Nearly half had previous hospitalizations (48.81%), 41.2% received antimicrobials, and 88.1% had undergone medical procedures before the onset of infection. The median time of onset of CRE infection was 16 days after admission. Common sites of infection were bacteremia (53.90%) and pneumonia (45.47%). Most CRE-infected patients had septic shock (63.10%) and Gram-negative co-infections (62.85%). Colistin (29.95%) and non-colistin (12.91%) monotherapies, and colistin-based (44.78%) and non-colistin-based (12.36%) combination therapies were the best available antimicrobial therapies (BAAT). The median length of hospitalization was 31 days, and the median hospitalization cost was US$10,435. The in-hospital mortality rate was 68.33%. Septic shock [adjusted odds ratio (aOR) 10.73, 5.65–20.42, p <0 .001], coinfection (aOR 2.43, 1.32–4.47, p = 0.004), mechanical ventilation (aOR 2.33, 1.24–4.36, p = 0.009), and a high SOFA score at onset (aOR 1.18, 1.07–1.30, p <0 .001) were associated with mortality.

Conclusion: CRE infection increases mortality, hospital stays, and healthcare costs. A colistin-based regimen was the BAAT in this study. Therefore, newer antimicrobial agents are urgently needed.