Relationship between digestive tract colonization and subsequent ventilator-associated pneumonia related to ESBL-producing Enterobacteriaceae

PLOS ONE, Aug 2018

Background Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection. Recently, the incidence of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE) has substantially increased in critically ill patients. Identifying patients at risk for VAP related to ESBLE could be helpful to improve the rate of appropriate initial antibiotic treatment, and to reduce unnecessary exposure to carbapenems. The primary objective was to identify risk factors for VAP related to ESBLE. Secondary objective was to determine the impact of ESBLE on outcome in VAP patients. Methods This retrospective study was conducted in a single mixed intensive care unit (ICU), during a 4-year period. All patients with confirmed VAP were included. VAP was defined using clinical, radiologic and quantitative microbiological data. VAP first episodes were prospectively identified using the continuous surveillance data. Exposure to different risk factors was taken into account until the diagnosis of ESBLE VAP or until ICU discharge, in patients with ESBLE VAP and VAP related to other bacteria, respectively. In all patients, routine screening for ESBLE (rectal swab) was performed at ICU admission and once a week. Patients with ESBLE VAP were compared with those with VAP related to other bacteria using univariate analysis. All significant factors were included in the multivariate logistic regression model. Results Among the 410 patients with VAP, 43 (10.5%) had ESBLE VAP, 76 (19%) patients had polymicrobial VAP and 189 (46%) had VAP related to multidrug resistant bacteria. Multivariate analysis identified prior ESBLE colonization of the digestive tract as the only independent risk factor for ESBLE VAP (OR [95% CI] = 23 [10–55], p < 0.001). Whilst the positive predictive value of ESBLE digestive colonization was low (43.6%), its negative predictive value was excellent (97.3%) in predicting ESBLE VAP. Duration of mechanical ventilation (median [IQR], 28 [18,42] vs 23 [15,42] d, p = 0.4), length of ICU stay (31 [19,53] vs 29 [18,46] d, p = 0.6), and mortality rates (55.8% vs 50%, p = 0.48) were similar in ESBLE VAP, compared with VAP related to other bacteria. Conclusion Digestive tract colonization related to ESBLE is independently associated with ESBLE VAP. Its excellent negative predictive value suggests that patients without ESBLE colonization should not receive carbapenems as part of their initial empirical treatment to cover ESBLE.

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Relationship between digestive tract colonization and subsequent ventilator-associated pneumonia related to ESBL-producing Enterobacteriaceae

August Relationship between digestive tract colonization and subsequent ventilator- associated pneumonia related to ESBL- producing Enterobacteriaceae Marion Houard 0 1 Anahita Rouze 0 1 Geoffrey Ledoux 0 1 Sophie Six 0 1 Emmanuelle Jaillette 0 1 Julien Poissy 0 1 Se bastien Pre au 0 1 Fre de ric Wallet 1 Julien Labreuche 1 Saad Nseir 0 1 Benoit Voisin 0 1 0 CHU Lille, Critical Care Center, Lille, France, 2 Univ. Lille, Faculty of Medicine, Lille, France , 3 CHU Lille , Centre de Biologie et de Pathologie, Lille, France , 4 CHU Lille , Clinique de Sant e Publique, Plateforme d'Aide M eÂthodologique , Lille , France 1 Editor: Yu Ru Kou, National Yang-Ming University , TAIWAN Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection. Recently, the incidence of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE) has substantially increased in critically ill patients. Identifying patients at risk for VAP related to ESBLE could be helpful to improve the rate of appropriate initial antibiotic treatment, and to reduce unnecessary exposure to carbapenems. The primary objective was to identify risk factors for VAP related to ESBLE. Secondary objective was to determine the impact of ESBLE on outcome in VAP patients. - Data Availability Statement: All relevant data are within the paper. Funding: The authors received no specific funding for this work. Competing interests: SN: Bayer (advisory board), and MSD (lecture); other authors: none. This does not alter our adherence to PLOS ONE policies on sharing data and materials. Background Methods This retrospective study was conducted in a single mixed intensive care unit (ICU), during a 4-year period. All patients with confirmed VAP were included. VAP was defined using clinical, radiologic and quantitative microbiological data. VAP first episodes were prospectively identified using the continuous surveillance data. Exposure to different risk factors was taken into account until the diagnosis of ESBLE VAP or until ICU discharge, in patients with ESBLE VAP and VAP related to other bacteria, respectively. In all patients, routine screening for ESBLE (rectal swab) was performed at ICU admission and once a week. Patients with ESBLE VAP were compared with those with VAP related to other bacteria using univariate analysis. All significant factors were included in the multivariate logistic regression model. Results Among the 410 patients with VAP, 43 (10.5%) had ESBLE VAP, 76 (19%) patients had polymicrobial VAP and 189 (46%) had VAP related to multidrug resistant bacteria. Multivariate analysis identified prior ESBLE colonization of the digestive tract as the only independent risk factor for ESBLE VAP (OR [95% CI] = 23 [10±55], p < 0.001). Whilst the positive predictive value of ESBLE digestive colonization was low (43.6%), its negative predictive value was excellent (97.3%) in predicting ESBLE VAP. Duration of mechanical ventilation (median [IQR], 28 [ 18,42 ] vs 23 [ 15,42 ] d, p = 0.4), length of ICU stay (31 [ 19,53 ] vs 29 [ 18,46 ] d, p = 0.6), and mortality rates (55.8% vs 50%, p = 0.48) were similar in ESBLE VAP, compared with VAP related to other bacteria. Conclusion Digestive tract colonization related to ESBLE is independently associated with ESBLE VAP. Its excellent negative predictive value suggests that patients without ESBLE colonization should not receive carbapenems as part of their initial empirical treatment to cover ESBLE. Introduction Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU) [1±3]. VAP is associated with high morbidity and attributable mortality, ranging from 10 to 30% in different studies [4±7]. VAP also leads to prolonged duration of mechanical ventilation and length of stay [7±9]. As inappropriate initial antimicrobial treatment is an important risk factor for mortality, the choice of empiric antimicrobial treatment for critically ill patients is often challenging [ 10,11 ]. Infections involving multidrug-resistant (MDR) bacteria are common in ICU and a negative impact on mortality is reported in patients with severe infections related to these bacteria [ 12,13 ]. Among MDR bacteria, extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE) became a serious threat. A recent meta-analysis of thirteen studies reported a rate of ICU-acquired ESBLE ranging 5±10% in the United States and Europe [ 14 ]. Previous use of beta-lactam/beta-lactamase or carbapenems and recent hospitalization were identified as risk factors for ESBLE colonization. In addition, digestive tract colonization was associated with significantly higher frequency of ESBLE subsequent infection and increased mortality [ 14 ]. According to the current guidelines, patients with risk factors for pneumonia related to MDR bacteria should receive broad-spectrum antimicrobial treatment [ 2,15 ]. Given the recent spread of ESBLE, this stra (...truncated)


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Marion Houard, Anahita Rouzé, Geoffrey Ledoux, Sophie Six, Emmanuelle Jaillette, Julien Poissy, Sébastien Préau, Frédéric Wallet, Julien Labreuche, Saad Nseir, Benoit Voisin. Relationship between digestive tract colonization and subsequent ventilator-associated pneumonia related to ESBL-producing Enterobacteriaceae, PLOS ONE, 2018, Volume 13, Issue 8, DOI: 10.1371/journal.pone.0201688