Abstract
BackgroundBloodstream infections (BSI) caused by Enterobacteriaceae show increasing frequency of resistance to third-generation cephalosporin (3GC) antibiotics on the African continent but the mortality impact has not been quantified.MethodsWe used historic data from six African hospitals to assess the impact of 3GC resistance on clinical outcomes in Escherichia coli and Klebsiella pneumoniae BSI. We matched each bacteraemic patient to two uninfected patients. We compared outcomes between 3GC-susceptible and 3GC-resistant BSI and their respective uninfected controls using Cox regression models.ResultsFor 1431 E. coli BSI patients, we matched 1152 (81%) 3GC-susceptible and 279 (19%) 3GC-resistant cases to 2263 and 546 uninfected inpatient controls. For 1368 K. pneumoniae BSI patients, we matched 502 (37%) 3GC-susceptible and 866 (63%) 3GC-resistant cases to 982 and 1656 uninfected inpatient controls. We found that 3GC-resistant E. coli had similar hazard ratios (HRs) for in-hospital mortality over their matched controls as compared to susceptible infections over their controls (ratio of HRs 1.03, 95% CI 0.73–1.46). Similarly, 3GC-resistance in K. pneumoniae BSI was not associated with mortality (ratio of HR 1.10, 95% CI 0.80–1.52). Estimates of mortality impact varied by site without a consistent pattern.ConclusionsIn a retrospective analysis, including the use of matched uninfected patients, there did not appear to be an impact of 3GC-resistance on mortality in E. coli or K. pneumoniae BSI in African hospitals, as compared with susceptible BSI with equivalent species. Better information on the actual use of antibiotics in treating infections in African hospitals would improve these impact estimates.
Highlights
High proportions of third-generation cephalosporin (3GC) resistance amongst E. coli and K. pneumoniae Bloodstream infections (BSI) have been reported from many African countries, often substantially exceeding the proportions found in high-income settings.[6,7,8,9]
A total of 1431 E. coli BSI and 1368 K. pneumoniae BSI episodes were identified from the six sites (Table 2), two hospitals (Kenya and South Africa) contributed much larger datasets (88% of the total E. coli and 82% of the total K. pneumoniae BSI patients)
Patients paid for blood culture sample processing, except for the South African site where patients did not pay for laboratory testing and in the Kenyan site where blood culturing was funded by research grants
Summary
Antibiotic resistance is a global challenge with major implications for African countries where severe bacterial infections are common, but access to antibiotics is often limited.[1,2] Bloodstream infections (BSI) caused by the pathogens Escherichia coli and Klebsiella pneumoniae are important contributors to neonatal, child and adult morbidity and mortality in Africa.[3,4,5] E. coli is a common cause of various community-acquired infections, whereas K. pneumoniae typically causes hospital-acquired infections.[3,6] High proportions of third-generation cephalosporin (3GC) resistance amongst E. coli and K. pneumoniae BSI have been reported from many African countries, often substantially exceeding the proportions found in high-income settings.[6,7,8,9] Clinically, 3GC-resistance is important as it usually protects bacteria against almost all antibiotics in the widely used penicillin and cephalosporin classes. Despite the increasing occurrence of 3GC-resistant BSI in Africa, regional estimates of the clinical impact of this, or any, form of antibiotic resistance on mortality and length of hospital stay (LOS) are scarce.[9]. Bloodstream infections (BSI) caused by Enterobacteriaceae show increasing frequency of resistance to third-generation cephalosporin (3GC) antibiotics on the African continent but the mortality impact has not been quantified
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