Hostname: page-component-8448b6f56d-gtxcr Total loading time: 0 Render date: 2024-04-18T10:11:32.776Z Has data issue: false hasContentIssue false
  • English
  • Français

Influx of Multidrug-Resistant, Gram-Negative Bacteria in the Hospital Setting and the Role of Elderly Patients With Bacterial Bloodstream Infection

Published online by Cambridge University Press:  02 January 2015

Aurora Pop-Vicas ,
E. Tacconelli ,
Stefan Gravenstein ,
Bing Lu  and
Erika M. C. D'Agata
Aurora Pop-Vicas
Affiliation:
Division of Infectious Diseases, Providence, Rhode Island
E. Tacconelli
Affiliation:
Department of Infectious Diseases, Catholic University, Rome, Italy
Stefan Gravenstein
Affiliation:
Memorial Hospital of Rhode Island, Pawtucket, and the Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
Bing Lu
Affiliation:
Center for Primary Care and Prevention, Providence, Rhode Island
Erika M. C. D'Agata*
Affiliation:
Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
*
Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 330 Brookline Ave., East Campus Mailstop SL-435G, Boston, MA 02215 (edagata@bidmc.harvard.edu)
Get access Rights & Permissions [Opens in a new window]

Abstract

Background.

Multidrug-resistant (MDR) gram-negative bacteria are reported increasingly frequently among isolates recovered from elderly patients. The clinical epidemiology of bloodstream infection (BSI) due to MDR gram-negative bacteria among elderly patients is unknown.

Objective.

To characterize the clinical epidemiology of BSI due to MDR gram-negative bacteria among elderly patients at hospital admission in an effort to provide a greater understanding of these serious infections and ultimately to improve patient outcomes.

Design.

Case-control study.

Setting.

Tertiary care hospital in Boston, Massachusetts.

Patients.

Patients 65 years of age and older.

Methods.

From 1999 to 2007, computerized medical records were reviewed for BSI due to MDR gram-negative bacteria within 48 hours of hospital admission. Risk factors for BSI due to these bacteria were identified.

Results.

MDR gram-negative bacteria were recovered from 61 (8%) of 724 elderly patients with BSI caused by gram-negative bacteria. Over the -year study period, the percentage of MDR gram-negative bacteria among bloodstream isolates increased from 2 (1%) of 199 to 34 (16%) of 216. Empiric therapy was ineffective for 38 (63%) of 60 patients with BSI caused by MDR gram-negative bacteria. The variables independently associated with BSI due to these bacteria were as follows: residency in a long-term care facility (odds ratio [OR], 4.9 [95% confidence interval {CI} 1.6–14.9]; P = .006), presence of an invasive device (OR, 6.0 [95% CI, 1.5–23.5]; P = .01), severe sepsis (OR, 7.9 [95% CI, 1.7–37.1]; P = .009), and delayed initiation of effective therapy (OR, 12.8 [95% CI, 3.9–41.1]; P<.001).

Conclusion.

The 16-fold increase in BSI due to MDR gram-negative bacteria at hospital admission among elderly patients, especially among those who resided in long-term care facilities prior to admission, contributes further to the expanding body of evidence that these patients are the main reservoirs of MDR gram-negative bacteria. Given their contribution to the influx of antimicrobial-resistant bacteria in the hospital setting, infection control interventions that target this high-risk group need to be considered.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 30 , Issue 4 , April 2009 , pp. 325 - 331
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Blot, S, Vandewoude, K, De Bacquer, D, et al.Nosocomial bacteremia caused by antibiotic-resistant gram-negative bacteria in critically ill patients: clinical outcome and length of hospitalization. Clin Infect Dis 2002;34:1600–1606.Google Scholar
2.Martin, GS, Mannino, DM, Moss, M. The effect of age on the development and outcome of adult sepsis. Crit Care Med 2006;34:15–21.Google Scholar
3.Jones, RN. Resistance patterns among nosocomial pathogens: trend over the past years. Chest 2001;119(S2):397S–404S.Google Scholar
4.Flournoy, DJ, Reinert, RL, Bell-Dixon, C, et al.Increasing antimicrobial resistance in gram-negative bacilli isolated from patients in intensive care units. Am J Infect Control 2000;28:244–250.Google Scholar
5.D'Agata, EMC. Rapidly rising prevalence of nosocomial multidrug-resistant, gram-negative bacilli: a 9-year surveillance study. Infect Control Hosp Epidemiol 2004;25:842–846.CrossRefGoogle ScholarPubMed
6.Karlowsky, JA, Jones, ME, Thornsberry, C, Friedland, IR, Sahm, DF. Trends in antimicrobial susceptibilities among Enterobacteriaceae isolates from hospitalized patients in the United States from 1998 to 2001. Antimicrob Agents Chemother 2003;47:1672–1680.Google Scholar
7.National Noscomial Infections Surveillance System 2004. Data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470–485.Google Scholar
8.O'Fallon, E, Pop-Vicas, A, D'Agata, EMC. The emerging threat of multi-drug resistant gram-negative organisms in a long-term care facilities. J Gerontol A Biol Sci Med Sci 2009 (in press).Google Scholar
9.Pop-Vicas, AE, D'Agata, EM. The rising influx of multidrug-resistant gram-negative bacilli into a tertiary care hospital. Clin Infect Dis 2005;40:1792–1798.Google Scholar
10.Garner, JS, Jarvis, WR, Emori, TG, Horan, TC, Hughes, J. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128–140.Google Scholar
11.Yu, VL, Chiou, CC, Feldman, C, et al.An international prospective study of pneumococcal bacteremia: correlation with in vitro resistance, anti-biotics administered, and clinical outcome. Clin Infect Dis 2003;37:230–237.Google Scholar
12.Paterson, DL, Ko, WC, Von Gottberg, S, et al.International prospective study of Klebsiella pneumoniae bacteremia: implications of extended-spectrum beta-lactamase production in nosocomial infections. Ann Intern Med 2004;140:26–32.Google Scholar
13.Charlson, M, Pompei, P, Ales, K, MacKenzie, CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987;40:373–383.Google Scholar
14.Clinical and Laboratory Standards Institute (CLSI). Performance standards for antimicrobial susceptibility testing: supplement M100-S16. Wayne, PA: CLSI, 2006.Google Scholar
15.Pfaller, MA, Segreti, J. Overview of the epidemiological profile and laboratory detection of extended-spectrum β-lactamases. Clin Infect Dis 2006;42(suppl 4):S153–S163.CrossRefGoogle ScholarPubMed
16.Opal, SM, Girard, TD, Ely, WE. The immunopathogenesis of sepsis in elderly patients. Clin Infect Dis 2005;41:S504–S512.Google Scholar
17.Harbarth, S, Garbino, J, Pugin, J, et al.Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med 2003;115:529–535.Google Scholar
18.Garnacho-Montero, J, Garcia-Garmendia, JL, Barrero-Almodovar, A, et al.Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis. Crit Care Med 2003;31:2742–2751.Google Scholar
19.Peralta, G, Sanchez, MB, Garrido, JC, et al.Impact of antibiotic resistance and of adequate empirical antibiotic treatment in the prognosis of patients with Escherichia coli bacteraemia. J Antimicrob Chemother 2007;60:855–863.Google Scholar
20.Kumar, A, Roberts, D, Wood, KE, et al.Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589–1596.Google Scholar
21.Wiener, J, Quinn, JP, Bradford, PA, et al.Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA 1999;281:517–523.Google Scholar
22.Trick, W, Weinstein, RA, DeMarais, PL, et al.Colonization of skilled-care facility residents with antimicrobial-resistant pathogens. J Am Geriatr Soc 2001;49:270–276.CrossRefGoogle ScholarPubMed
23.Bonomo, R. Multiple antibiotic-resistant bacteria in long-term-care facilities: an emerging problem in the practice of infectious diseases. Clin Infect Dis 2000;31:1414–1422.Google Scholar
24.Nicolle, LE. Preventing infections in non-hospital settings: long-term care. Emerg Infect Dis 2001;7:205–207.Google Scholar
25.Loeb, M, Simor, AE, Landry, L, et al.Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med 2001;16:376–383.Google Scholar
26.Warren, JW, Palumbo, FB, Fitterman, L, Speedie, SM. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr Soc 1991;39:963–972.Google Scholar
27.Zimmer, JG, Bentley, DW, Valenti, WM, et al.Systemic antibiotic use in nursing homes: a quality assessment. J Am Geriatr Soc 1986;34:703–710.Google Scholar
28.Pickering, TD, Gurwitz, JH, Zaleznik, D, et al.The appropriateness of oral fluoroquinolone-prescribing in the long-term care setting. J Am Geriatr Soc 1994;42:28–32.Google Scholar
29.Jones, SR, Parker, DF, Liebow, ES, et al.Appropriateness of antibiotic therapy in long-term care facilities. Am J Med 1987;83:499–502.Google Scholar
30.D'Agata, EMC, Mitchell, SL. Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med 2008;168:357–362.Google Scholar
31.Pop-Vicas, A, Strom, T, D'Agata, EMC. Multidrug-resistant gram-negative bacilli among patients who require chronic hemodialysis. Clin J Am Soc Nephrol 2008;3:752–758.Google Scholar
32.Nicolle, LE, Bentley, D, Garibaldi, R, et al.Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 1996;17:119–128.Google Scholar
33.D'Agata, EMC. Methodological issues of case-control studies: a review of established and newly recognized limitations. Infect Control Hosp Epidemiol 2005;26:338–341.Google Scholar
34.Falagas, M, Koletsi, P, Bliziotis, I. The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acinetobacter baumannii and Pseudomonas aeruginosa. J Med Microbiol 2006;55:1619–1629CrossRefGoogle ScholarPubMed
35.Harris, AD, Samore, MH, Lipsitch, M, et al.Control-group selection importance in studies of antimicrobial resistance: examples applied to Pseudomonas aeruginosa, Enterococci, and Escherichia coli. Clin Infect Dis 2002;34:1558–1563.Google Scholar