Abstract
BackgroundHealthcare exposure may increase drug-resistant Enterobacteriaceae colonization risk. Nascent antimicrobial stewardship efforts in low- and middle-income countries require setting-specific data. We aimed to evaluate risk factors for inpatient drug resistant Enterobacteriaceae colonization in a resource-limited setting in India.MethodsPatients age ≥ 6 months admitted with ≥24 h of fever to a tertiary hospital in Pune, India were enrolled in a prospective cohort. Perirectal swabs, collected on admission and hospitalization day 3 or 4, were cultured in vancomycin- and ceftriaxone-impregnated media to assess for ceftriaxone-resistant Enterobacteriaceae (CTRE) and carbapenem-resistant Enterobacteriaceae (CPRE). Multivariable analyses assessed risk factors for drug-resistant Enterobacteriaceae colonization among participants without admission colonization.ResultsAdmission perirectal swabs were collected on 897 participants; 87 (10%) had CTRE and 14 (1.6%) had CPRE colonization. Admission CTRE colonization was associated with recent healthcare contact (p < 0.01). Follow-up samples were collected from 620 participants, 67 (11%) had CTRE and 21 (3.4%) had CPRE colonization. Among 561 participants without enrollment CTRE colonization, 49 (9%) participants were colonized with CTRE at follow-up. Detection of CTRE colonization among participants not colonized with CTRE at admission was independently associated with empiric third generation cephalosporin treatment (adjusted odds ratio [OR] 2.9, 95% CI 1.5–5.8). Follow-up transition to CPRE colonization detection was associated with ICU admission (OR 3.0, 95% CI 1.0–8.5).ConclusionsPatients who receive empiric third generation cephalosporins and are admitted to the ICU rapidly develop detectable CTRE and CPRE colonization. Improved antimicrobial stewardship and infection control measures are urgently needed upon hospital admission.
Highlights
Healthcare exposure may increase drug-resistant Enterobacteriaceae colonization risk
Colonization with ceftriaxone-resistant Enterobacteriaceae (CTRE) at enrollment was higher in participants who had recent contact with the healthcare system including recently hospitalization, outpatient visit prior to hospitalization, or self-reported antibiotic use in the last month (Table 1)
We found that participants without baseline CTRE colonization who received empiric third generation cephalosporins had almost three-fold higher odds of follow up detection of CTRE colonization, and were more likely to acquire carbapenem-resistant Enterobacteriaceae (CPRE) colonization if admitted to the intensive care unit (ICU)
Summary
Healthcare exposure may increase drug-resistant Enterobacteriaceae colonization risk. We aimed to evaluate risk factors for inpatient drug resistant Enterobacteriaceae colonization in a resource-limited setting in India. Antibiotic use is increasing worldwide and has been implicated in the dramatic rise of antimicrobial resistance, which in turn threatens to reverse historical reductions in mortality for infectious diseases [1]. Infections with drug-resistant Enterobacteriaceae, such as those producing ESBL, have been associated with increased mortality [2]. The gut serves as a reservoir for drug-resistant Enterobacteriaceae [3]. Antibiotic administration increases drug-resistant Enterobacteriaceae colonization through selection pressure and disruption of protective normal microbiota [3, 4]. Animal models show a disruption to the gut microbiome within 12 h and emergence of drug resistance genes within 3 days of antibiotic administration [5, 6]. Patients colonized with ESBL-producing Enterobacteriaceae are at greater risk for clinical infections with ESBL-producing Enterobacteriaceae than those who are not colonized [7]
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