| Abstract |
Background: Antibiotic-resistant infections, particularly those caused by multidrugresistant
(MDR) organisms, pose a major threat to public health. Amongst MDR
organisms, the group named as ESKAPEE, an acronym for Enterococcus faecium,
Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii,
Pseudomonas aeruginosa, Enterobacter spp., and Escherichia coli, poses major
concern and is classified by the World Health Organization as Critical Priority
pathogens.
Objective: This study assessed patterns and trends of antimicrobial resistance in
ESKAPEE blood isolates from hospitalized patients and examined their association
with patient mortality and length of hospital stay in a 140-bed secondary-care
general hospital in Greece.
Methods: In a retrospective observational cohort design, we retrieved all positive
blood cultures for ESKAPEE organisms and their antibiotic susceptibility tests
performed in the hospital’s microbiology lab from July 2016 to June 2021. We
categorized multiresistance levels as MDR, extensively drug-resistant (XDR) and
pandrug-resistant (PDR) using internationally accepted definitions. We examined
temporal patterns and trends of multiresistance levels and their impact on patient
outcome by means of logistic and Cox regression models.
Results: 199 patients had a blood culture positive for ESKAPEE (209 organisms, 4.5%
polymicrobial cultures) over the 5-year study period, for an overall incidence rate of
1.7 cases per 1,000 patient-days (95% confidence interval [CI], 1.5-2.0). Affected
patients had median age 75 years, 57.8% were men, 65.3% had history of previous
hospitalization, and 34.2% were admitted in the intensive care unit (ICU). Any-cause
in-hospital mortality was 28.6% and the median length of hospitalization was 13
days. The four most common ESKAPEE organisms were E. coli (32.7%), Enterococcus
spp. (19.1%), S. aureus (18.6%), and A. baumannii (15.1%). The respective MDR
proportions were 21.5% for E. coli, 36.8% for Enterococcus spp (including 7.9%
glycopeptide resistant), 32.4% for S. aureus (including 16.2% methicillin resistant),
and 100% for A. baumannii (including 6.7% XDR and 13.3% possible PDR). Overall,
there were 8 isolates classified as XDR (6 A. baumannii isolates, of which 4 were
possible PDR and 2 P. aeruginosa isolates). A statistically significant trend of
increasing MDR incidence over time was observed only for S. aureus. Case-fatality
proportions were 24.3%, 32.1% and 57.1% in patients who had a non-MDR, MDR and
XDR/PDR blood isolate, respectively (test for trend p = 0.061). In multivariable
analysis, A. baumannii was associated death (Odds Ratio [OR] 4.26; 95%CI 1.67 - 10.84; p = 0.002) and increased daily rate
of in-hospital death (cause-specific Hazard Ratio [csHR] 3.07; 95%CI 1.50 - 6.30;
p=0.002) within 14 days of positive culture and independently of the patient’s age
and underlying condition. In contrast, S. aureus was associated with increased 14-
day survival (OR 0.27; 95%CI 0.08 – 0.96; p = 0.043 and csHR 0.35; 95%CI 0.11 – 1.14;
p = 0.083). Enterococcus spp was not associated with patient mortality but was
found to decrease the daily rate of discharge-alive thereby increasing the length of
hospitalization.
Conclusion: While generally consistent with prior studies, the variations in
pathogens and drug resistance patterns and associated mortality by pathogen are
different from those observed in larger tertiary-care hospitals in Greece and
elsewhere, emphasizing the importance of local epidemiological surveillance
systems. In our setting, extensive antibiotic resistance was almost uniquely
associated with A. baumannii, which was strongly and independently associated with
increased in-hospital mortality.
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Επιδημιολογική διερεύνηση της διαχρονικής εξέλιξης της αντιμικροβιακής αντοχής σε σημαντικούς παθογόνους μικροοργανισμούς και εκτίμηση της επιβάρυνσης των ασθενών σε Γενικό Νοσοκομείο της Κρήτης.
