Healthcare-Associated Infections Caused by Multidrug-Resistant Organisms: Risk Factors, Clinical Outcomes, and Prevention Strategies
DOI:
https://doi.org/10.66687/jebmr.1.01.2025.45Palabras clave:
healthcare-associated infection, antimicrobial resistance, multidrug-resistant organisms, empirical antimicrobial therapy, septic shock, infection prevention, multicentre cohortResumen
Background: Multidrug-resistant organisms (MDROs) complicate healthcare-associated infections (HAIs), yet the relationships among antecedent exposures, initial antimicrobial activity, patient outcomes, and prevention-related exposures require careful interpretation among patients already infected. We compared MDR and non-MDR HAIs across eight hospitals in New York, USA.
Methods: This multicentre observational cohort study analysed 650 adults with culture-confirmed HAIs occurring more than 48 hours after admission across eight anonymised hospitals in New York, USA, between January 2024 and June 2024. The primary endpoint was MDR status at the index infection; secondary endpoints included active empirical therapy, septic shock, post-HAI hospital stay, in-hospital death and 30-day all- cause death. Logistic regression models adjusted for clinical covariates and hospital and infection-site indicators; negative-binomial regression assessed post-HAI stay. Associations are presented with 95% confidence intervals (CIs).
Results: Among 650 patients, 193 (29.7%) had MDR HAIs. MDR status was associated with prior antibiotic exposure (adjusted odds ratio [aOR] 2.44, 95% CI 1.64–3.63), documented MDRO colonisation (aOR 4.87, 2.98–7.96), previous hospitalisation (aOR 1.60, 1.10–2.35), and an early central line (aOR 1.76, 1.14–2.73). An admission prevention-bundle indicator was inversely associated with MDR status (aOR 0.45, 0.31–0.66). Active initial therapy occurred in 51.8% of MDR versus 87.1% of non-MDR cases. MDR HAIs were associated with septic shock (aOR 1.68, 1.04– 2.72) and longer post-HAI stay (adjusted incidence-rate ratio 1.37, 1.24–1.50), but not 30-day mortality (aOR 1.06, 0.60–1.85).
Conclusions: Among patients already experiencing HAIs, antecedent antibiotic use and MDRO carriage identified important resistance-associated profiles, while MDR cases experienced substantial treatment mismatch and morbidity. Prevention-bundle associations are noncausal, and mortality differences remained uncertain. Multicentre validation and intervention studies are warranted.
Referencias
Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care–associated infections in U.S. hospitals. N Engl J Med. 2018;379:1732–1744. doi:10.1056/NEJMoa1801550.
Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377:228–241. doi:10.1016/S0140-6736(10)61458-4.
Vincent JL, Sakr Y, Singer M, et al. Prevalence and outcomes of infection among patients in intensive care units in 2017. JAMA. 2020;323:1478–1487. doi:10.1001/jama.2020.2717.
Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399:629–655. doi:10.1016/S0140-6736(21)02724-0.
GBD 2021 Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. Lancet. 2024;404:1199–1226. doi:10.1016/S0140-6736(24)01867-1.
Cassini A, Högberg LD, Plachouras D, et al. Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and European Economic Area in 2015. Lancet Infect Dis. 2019;19:56–66. doi:10.1016/S1473-3099(18)30605-4.
de Kraker MEA, Davey PG, Grundmann H. Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: estimating the burden of antibiotic resistance in Europe. PLoS Med. 2011;8:e1001104. doi:10.1371/journal.pmed.1001104.
Holmes AH, Moore LSP, Sundsfjord A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387:176–187. doi:10.1016/S0140-6736(15)00473-0.
Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance—the need for global solutions. Lancet Infect Dis. 2013;13:1057–1098. doi:10.1016/S1473-3099(13)70318-9.
Tacconelli E, Carrara E, Savoldi A, et al. Discovery, research, and development of new antibiotics: the WHO priority list of antibiotic-resistant bacteria and tuberculosis. Lancet Infect Dis. 2018;18:318–327. doi:10.1016/S1473-3099(17)30753-3.
Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18:268–281. doi:10.1111/j.1469-0691.2011.03570.x.
Schwaber MJ, Carmeli Y. Mortality and delay in effective therapy associated with extended-spectrum beta-lactamase production in Enterobacteriaceae bacteraemia: a systematic review and meta-analysis. J Antimicrob Chemother. 2007;60:913–920. doi:10.1093/jac/dkm318.
Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115:462–474. doi:10.1378/chest.115.2.462.
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34:1589–1596. doi:10.1097/01.CCM.0000217961.75225.E9.
Ferrer R, Martin-Loeches I, Phillips G, et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med. 2014;42:1749–1755. doi:10.1097/CCM.0000000000000330.
Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017;376:2235–2244. doi:10.1056/NEJMoa1703058.
Paul M, Shani V, Muchtar E, Kariv G, Robenshtok E, Leibovici L. Systematic review and meta-analysis of the efficacy of appropriate empiric antibiotic therapy for sepsis. Antimicrob Agents Chemother. 2010;54:4851–4863. doi:10.1128/AAC.00627-10.
Schuts EC, Hulscher MEJL, Mouton JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16:847–856. doi:10.1016/S1473-3099(16)00065-7.
Baur D, Gladstone BP, Burkert F, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17:990–1001. doi:10.1016/S1473-3099(17)30325-0.
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732. doi:10.1056/NEJMoa061115.
Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255–2265. doi:10.1056/NEJMoa1207290.
Anderson DJ, Chen LF, Weber DJ, et al. Enhanced terminal room disinfection and acquisition and infection caused by multidrug-resistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised, multicentre, crossover study. Lancet. 2017;389:805–814. doi:10.1016/S0140-6736(16)31588-4.
Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43:553–569. doi:10.1017/ice.2022.87.
Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43:687–713. doi:10.1017/ice.2022.88.
Patel PK, Advani SD, Kofman AD, et al. Strategies to prevent catheter-associated urinary tract infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44:1209–1231. doi:10.1017/ice.2023.137.
Calderwood MS, Anderson DJ, Bratzler DW, et al. Strategies to prevent surgical site infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44:695–720. doi:10.1017/ice.2023.67.
Popovich KJ, Aureden K, Ham DC, et al. SHEA/IDSA/APIC practice recommendation: strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44:1039–1067. doi:10.1017/ice.2023.102.
Yokoe DS, Advani SD, Anderson DJ, et al. Executive summary: a compendium of strategies to prevent healthcare-associated infections in acute-care hospitals: 2022 updates. Infect Control Hosp Epidemiol. 2023;44:1540–1554. doi:10.1017/ice.2023.138.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4:e296. doi:10.1371/journal.pmed.0040296.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383. doi:10.1016/0021-9681(87)90171-8.
Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22:707–710. doi:10.1007/BF01709751.
Harris AD, Pineles L, Belton B, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA. 2013;310:1571–1580. doi:10.1001/jama.2013.277815.
de Smet AMGA, Kluytmans JAJW, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med. 2009;360:20–31. doi:10.1056/NEJMoa0800394.
Rhee C, Dantes R, Epstein L, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009–2014. JAMA. 2017;318:1241–1249. doi:10.1001/jama.2017.13836.
Liu VX, Fielding-Singh V, Greene JD, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017;196:856–863. doi:10.1164/rccm.201609-1848OC.
Timbrook TT, Morton JB, McConeghy KW, Caffrey AR, Mylonakis E, LaPlante KL. The effect of molecular rapid diagnostic testing on clinical outcomes in bloodstream infections: a systematic review and meta-analysis. Clin Infect Dis. 2017;64:15–23. doi:10.1093/cid/ciw649.
