P1459 Paper Poster Session Urinary tract infections
Bacteriuria due to carbapenem-resistant Enterobacteriaceae in critically ill patients: what comes next?
Leandro Perez*1, Diógenes Rodrigues2, Fabiano Ramos3, Cícero Dias4
1Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
2Hospital Mãe de Deus, Porto Alegre, Brazil
3Hospital São Lucas Da Puc, Porto Alegre, Brazil
4Universidade Federal de Ciências Da Saúde de Porto Alegre, Porto Alegre, Brazil
Background: Carbapenem-resistant Enterobacteriaceae (CRE) has been associated with serious infections and high mortality rates. Our objective was to assess the impact of therapy on the outcomes and the emergence of antimicrobial resistance among CRE bacteriuria/bacteremia in a cohort of critically ill patients.
Material/methods: From July 2013 to November 2015, a prospective cohort study was conducted in an adult ICU in a tertiary-care hospital in Porto Alegre, Brazil. Patients were included at the time of their first urine culture in which a CRE was recovered. Isolates with resistance to carbapenems were identified by MicroScan® and confirmed by Etest®. The presence of carbapenemase was detected by phenotypic testing and PCR. The primary outcomes were determined by result of a subsequent urine culture (negative or recurrent/subsequent bacteriuria) and/or within the 90-day bacteremia and by a 30-day mortality for patients with bacteremia by the same CRE. Development of antimicrobial resistance was evaluated comparing results from the first isolate with those obtained in a subsequent sample (urine or blood).
Results: A total of 109 patients were included. In eighty-five patients, KPC-2-producers (mostly Klebsiella pneumoniae - Kp) were recovered while, in the remaining 24, a culture with carbapenemase nonproducers (nCPE) was obtained. Nineteen out of 85 patients with KPC-2-Kp bacteriuria died during the 30-day period; 27 had a negative urine culture or were discharged; 14 had a bacteriuria with a microorganism other than KPC-2; and 25 had a recurrent KPC-2-Kp bacteriuria. Moreover, 15 patients, including 5 patients that also had a recurrent urinary isolate, presented an episode of bacteremia due to KPC-2-Kp and the 30-day mortality for these patients was 46.7% (Table). Regarding nCPE, no patient had a bacteremia, and only 4 of them presented a recurrent bacteriuria. In 35 patients a KPC-2-Kp was recovered in a subsequent bacteriuria/bacteremia case and a minor resistance increase was observed for polymyxin B (34.3 vs 42.8%), gentamicin (57.1 vs 68.6%), amikacin and tigecycline (14.3 vs 25.7%). For fosfomycin (more used nowadays) a significant resistance increase was detected (11.4 vs 34.3%, OR=4.04, 95%CI 1.1-14.2, p=0.03). On the other hand, no increase of antimicrobial resistance was observed among nCPE.
Conclusions: Only KPC-2-Kp caused bacteremia and the mortality was quite high. Furthermore, increase in antimicrobial resistance, mostly to fosfomycin, was driven by previous use. Table. Microbiological characteristics and clinical outcomes CRE bacteriuria Carbapenemase Urinary outcome Bacteremia 30-day mortality (n°/total n°, %) (n°/total n°, %) (n°/total n°, %) (n°/total n°, %) Klebsiella pneumoniae (82/109, 75.2) KPC-2 Recurrence (25/82, 30.5) Yes (15/82, 18.3) Yes (7/15, 46.7) Enterobacter cloacae (18/109, 16.5) None NSC* (13/18, 72.2) No NA** K. pneumoniae (6/109, 5.5) None NSC (4/6, 66.7) No NA Escherichia coli (3/109, 2.7) KPC-2 NSC (3/3, 100) No NA * Negative Subsequent Culture ** Not Applied