Abstract
Carbapenem-resistant Enterobacteriaceae conferred by New Delhi metallo-b-lactamase (NDM-1) resistance mechanism are endemic in India and Southeast Asia. An understanding of risk factors for NDM-1 infections is necessary to guide prevention strategies. We performed a retrospective case-control study of patients admitted at Christian Medical College Hospital, Vellore, India between May 2010 and August 2014 with Klebsiella pneumoniae blood stream infection (BSI). We compared patients with BSI caused by NDM-1 producing strains to two control groups: BSI with other multidrug resistant (MDR) strains and BSI with pan-susceptible strains. The study groups were assessed for risk factors for the outcomes: (1) infection with any MDR strain compared to pan-susceptible; and, (2) infection with NDM-1 strain as compared with other MDR and (3) Mortality. A total of 101 patients with BSI with NDM-1 producing Klebsiella pneumoniae were matched to two groups of controls: 112 with non-NDM-1 MDR strains and 101 with pan-susceptible strains. Medical (OR 10.4) and neonatal (OR 0.7) ICU admission, central venous catheter placement (CVC, OR 7.4) predicted MDR BSI. Prior carbapenem use (OR 8.4) and CVC (OR 4.8) predicted acquisition of an NDM-1 strain. Significant predictors for mortality included ICU stay (OR 3.0), mechanical ventilation (OR 3.2), female gender (OR 2.2), diabetes (OR 0.4). CVC placement, prior carbapenem use and ICU admission were significantly associated with BSI with NDM-1 producing and other MDR strains.
Highlights
Antimicrobial resistance, among Enterobacteriaceae is associated with worse healthcare outcomes including longer hospitalisations, greater healthcare expenditures, as well as increased morbidity and mortality [1]
This study was a retrospective case-control study of blood stream infection (BSI) with Klebsiella pneumoniae conducted at the Christian Medical College Hospital (CMCH), a 2858 bed tertiary care hospital serving over 2.5 million patients annually, in Vellore, South India
A total of 101 patients with BSI with NDM-1 producing Klebsiella pneumoniae were matched to 112 controls with multi-drug resistant (MDR) organisms 101 patients with pan-susceptible organisms
Summary
Antimicrobial resistance, among Enterobacteriaceae is associated with worse healthcare outcomes including longer hospitalisations, greater healthcare expenditures, as well as increased morbidity and mortality [1]. Given the frequent resistance of Enterobacteriaceae to fluoroquinolones and extended-spectrum β lactamases (ESBL), carbapenems have been the treatment of choice for multi-drug resistant (MDR) gram-negative organisms. Their increasing use, has led to the emergence of carbapenem-resistant Enterobacteriaceae (CRE) strains for which available therapeutic options are limited and associated mortality is high [2, 3]. In 2008, a new mechanism of carbapenem-resistance, New Delhi metallo-b-lactamase (NDM-1) was identified in isolates from the urine of a Swedish patient admitted to a hospital in New Delhi [4]. Based on in vitro testing, therapeutic options for patients with NDM producing strains are often limited to agents such as polymyxins with significant toxicity, though high dose carbapenem regimens and combination therapies have been tried [8]
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