Guido Bertolini1, Giovanni Nattino1, Carlo Tascini2, Daniele Poole3, Bruno Viaggi4, Greta Carrara5, Carlotta Rossi1, Daniele Crespi1, Matteo Mondini1, Martin Langer6, Gian Maria Rossolini7,8, Paolo Malacarne9. 1. GiViTI Coordinating Center, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Bergamo, Ranica, Italy. 2. Prima Divisione di Malattie Infettive, Ospedale Cotugno, Azienda Ospedaliera dei Colli, Napoli, Italy. 3. Servizio Anestesia e Rianimazione, Ospedale Civile San Martino, Belluno, Italy. 4. Anestesia e Rianimazione CTO, Azienda Ospedaliera Universitaria Careggi, Florence, Italy. 5. GiViTI Coordinating Center, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Bergamo, Ranica, Italy. greta.carrara@marionegri.it. 6. IRCCS Istituto Nazionale dei Tumori, Milano, Italy. 7. Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Florence, Italy. 8. SOD Microbiologia e Virologia, Azienda Ospedaliera Universitaria Careggi, Florence, Italy. 9. Rianimazione/Pronto Soccorso, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
Abstract
PURPOSE: To evaluate the prognostic importance of different Klebsiella spp. sensitivity patterns: multi-susceptible Klebsiella (MS-K), extended-spectrum cephalosporin-resistant, but carbapenem-susceptible Klebsiella (ESCR-CS-K), and carbapenem-resistant Klebsiella (CR-K). METHODS: We developed a prognostic model to predict hospital mortality in patients with infection on admission to the intensive care units (ICUs), and assessed its calibration in the subgroups of interest: patients with infections due to MS-K, ESCR-CS-K, CR-K. We assessed the calibration of the model also in ESCR-CS-K treated empirically with carbapenems and with piperacillin-tazobactam. RESULTS: A total of 13,292 adults with an ongoing infection were admitted to 137 Italian ICUs in 2012-2013. Of 801 Klebsiella spp. infected patients, 451 had MS-K, 116 ESCR-CS-K, and 234 CR-K. The prognostic model calibrated well for the MS-K and ESCR-CS-K subgroups. In the CR-K subgroup there were more deaths than predicted (standardized mortality ratio 1.20; 95% CI 1.08-1.31), indicating a negative prognostic role of the infection, mainly in the medium and high risk-of-death patients. When infection was caused by ESCR-CS-K, treatment with piperacillin-tazobactam increased adjusted mortality among the most severe patients (similarly to CR-K), while treatment with carbapenems did not (similarly to MS-K). CONCLUSIONS: In low risk-of-death patients admitted to the ICU with a Klebsiella spp. infection, the appropriateness of empirical antibiotic therapy seemed uninfluential to eventual mortality, while it appeared to be crucial in high-risk ones. The use of piperacillin-tazobactam may be inappropriate in severe patients with ESCR-CS-K infection. CR-K is associated to a significant 20% increase of adjusted mortality, only for patients at higher risk of death.
PURPOSE: To evaluate the prognostic importance of different Klebsiella spp. sensitivity patterns: multi-susceptible Klebsiella (MS-K), extended-spectrum cephalosporin-resistant, but carbapenem-susceptible Klebsiella (ESCR-CS-K), and carbapenem-resistant Klebsiella (CR-K). METHODS: We developed a prognostic model to predict hospital mortality in patients with infection on admission to the intensive care units (ICUs), and assessed its calibration in the subgroups of interest: patients with infections due to MS-K, ESCR-CS-K, CR-K. We assessed the calibration of the model also in ESCR-CS-K treated empirically with carbapenems and with piperacillin-tazobactam. RESULTS: A total of 13,292 adults with an ongoing infection were admitted to 137 Italian ICUs in 2012-2013. Of 801 Klebsiella spp. infected patients, 451 had MS-K, 116 ESCR-CS-K, and 234 CR-K. The prognostic model calibrated well for the MS-K and ESCR-CS-K subgroups. In the CR-K subgroup there were more deaths than predicted (standardized mortality ratio 1.20; 95% CI 1.08-1.31), indicating a negative prognostic role of the infection, mainly in the medium and high risk-of-deathpatients. When infection was caused by ESCR-CS-K, treatment with piperacillin-tazobactam increased adjusted mortality among the most severe patients (similarly to CR-K), while treatment with carbapenems did not (similarly to MS-K). CONCLUSIONS: In low risk-of-deathpatients admitted to the ICU with a Klebsiella spp. infection, the appropriateness of empirical antibiotic therapy seemed uninfluential to eventual mortality, while it appeared to be crucial in high-risk ones. The use of piperacillin-tazobactam may be inappropriate in severe patients with ESCR-CS-K infection. CR-K is associated to a significant 20% increase of adjusted mortality, only for patients at higher risk of death.
Entities:
Keywords:
Attributable mortality; Drug resistance; Intensive care units; Klebsiella infections; Multicenter study
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