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Differences in mortality between infections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniae and Escherichia coli

Published online by Cambridge University Press:  02 July 2018

Jason P. Burnham*
Affiliation:
Division of Infectious Diseases Washington University School of Medicine, St Louis, Missouri;
Jennie H. Kwon
Affiliation:
Division of Infectious Diseases Washington University School of Medicine, St Louis, Missouri;
Margaret A. Olsen
Affiliation:
Division of Infectious Diseases Washington University School of Medicine, St Louis, Missouri;
Hilary M. Babcock
Affiliation:
Division of Infectious Diseases Washington University School of Medicine, St Louis, Missouri;
Marin H. Kollef*
Affiliation:
Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri.
*
Author for correspondence: Jason P. Burnham, MD, Division of Infectious Diseases Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110. E-mail: burnham@wustl.edu or Marin H. Kollef, MD, Division of Pulmonary and Critical Care, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110. E-mail: kollefm@wustl.edu
Author for correspondence: Jason P. Burnham, MD, Division of Infectious Diseases Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110. E-mail: burnham@wustl.edu or Marin H. Kollef, MD, Division of Pulmonary and Critical Care, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St Louis, MO 63110. E-mail: kollefm@wustl.edu
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Abstract

Type
Letter to the Editor
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

To the Editor—We read with interest the recent article by Scheuerman et al,Reference Scheuerman, Schechner and Carmeli 1 in which they found that patients with extended-spectrum-β-lactamase (ESBL) producing Klebsiella pneumoniae infections had higher 30-day mortality than patients with ESBL producing Escherichia coli infections. We have recently published on mortality, readmissions, recurrences, and the benefit of infectious diseases consultation for patients with various multidrug resistant organism infections.Reference Burnham, Kwon, Olsen, Babcock and Kollef 2 , Reference Burnham, Olsen, Stwalley, Kwon, Babcock and Kollef 3 We included in our study patients with various ESBL producing Enterobacteriaceae infections, among them K. pneumoniae and E. coli. Given the recent findings of Scheuerman et al, we conducted a retrospective evaluation to determine the association between ESBL producing organism (K. pneumoniae or E. coli) and 30-day all-cause mortality at our institution.

This study was conducted at Barnes-Jewish Hospital, a 1,250-bed academic medical center in St Louis, Missouri. The study period was January 1, 2006, to October 1, 2015. We included patients with positive sterile site and bronchial wash/bronchoalveolar lavage cultures for ESBL-producing E. coli and K. pneumoniae. Sterile sites were defined as bloodstream; pleural, intra-abdominal, pericardial, cerebrospinal, and synovial fluids; bone marrow; and surgical specimens collected from lymph nodes, central nervous system, liver, spleen, kidney, pancreas, ovary, or vascular tissue. The presence of ESBL production was assumed based on ceftriaxone, aztreonam, cefotaxime, or ceftazidime nonsusceptibility. 4 The Washington University School of Medicine Institutional Review Board approved this study with a waiver of informed consent.

The primary endpoint was 30-day all-cause mortality. Kaplan-Meier curves for 30-day all-cause mortality were generated to compare organism type and significance determined using the log-rank test. Escherichia coli was used as the reference group for determining the association between organism and mortality. Log-log survival plots were used to graphically test the proportional hazards assumption. Factors associated with mortality in bivariate analysis (P<.20) were entered into a multivariate Cox proportional hazards model to determine hazard ratios (HR) for 30-day all-cause mortality. All analyses were conducted with SPSS version 25 software (IBM, Armonk, NY).

In total, 605 patients met the eligibility criteria: 543 with ESBL E. coli and 62 with ESBL K. pneumoniae. Among patients with ESBL E. coli, 96 (17.7%) died within 30 days compared to 16 (25.8%) with ESBL K. pneumoniae. In Kaplan-Meier analysis, mortality was not significantly different between patients infected with K. pneumoniae and E. coli ESBL organisms (P=0.12). Variables retained in the final Cox proportional hazards model are shown in Table 1. Infection with ESBL-producing K. pneumoniae was marginally associated with mortality in the final Cox proportional hazards model (hazard ratio [HR], 1.69; 95% confidence interval [CI], 0.97–2.92; P=.062). Because the number of patients in the ESBL K. pneumoniae group was small, we performed a post-hoc power analysis and found that we had only 35.8% power to detect a significant difference in mortality.

Table 1 Factors Associated with 30-Day All-Cause Mortality in a Cox Proportional Hazards ModelFootnote a

NOTE. HIV/AIDS, human immunodeficiency virus/acquired immunodeficiency syndrome; APACHE, Acute Physiology and Chronic Health Evaluation; CI, confidence interval; HR, hazard ratio; ICU, intensive care unit; ID, infectious diseases.

a Variables not retained in final model included admitting service, sex, lymphoma, congestive heart failure, diabetes, solid organ transplant, bone marrow transplant, chronic kidney disease, and end-stage renal disease.

Our results add to the body of literature on differences in mortality between ESBL-producing K. pneumoniae and E. coli. Despite the low power of our study, ESBL-producing K. pneumoniae was associated with marginally increased risk of 30-day mortality. Our data are important to add to the literature on this subject and could be combined with the data of Scheuerman et al and future studies in a meta-analysis to more definitively determine the association between ESBL-producing organism type and mortality. In addition, as demonstrated in our previous study, infectious disease consultation was associated with reduced mortality for drug-resistant Enterobacteriaceae infections.

Acknowledgments

The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health (NIH).

Financial support

This work was supported by a grant from the Washington University Institute of Clinical and Translational Sciences (grant no. UL1TR000448) and by a subaward (no. KL2TR000450) from the National Center for Advancing Translational Sciences (NCATS) of the NIH.

Potential conflicts of interest

Dr Kollef was supported by the Barnes-Jewish Hospital Foundation. All other authors report no conflicts of interest relevant to this article.

Footnotes

Cite this article: Burnham JP, et al. (2018). Differences in mortality between infections due to extended-spectrum-beta-lactamase–producing Klebsiella pneumoniae and Escherichia coli. Infection Control & Hospital Epidemiology 2018, 39, 1138–1139. doi: 10.1017/ice.2018.142

References

1. Scheuerman, O, Schechner, V, Carmeli, Y, et al. Comparison of predictors and mortality between bloodstream infections caused by ESBL-producing Escherichia coli and ESBL-producing Klebsiella pneumoniae . Infect Control Hosp Epidemiol 2018;39:660667.CrossRefGoogle ScholarPubMed
2. Burnham, JP, Kwon, JH, Olsen, MA, Babcock, HM, Kollef, MH. Readmissions with multidrug-resistant infection in patients with prior multidrug-resistant infection. Infect Control Hosp Epidemiol 2018;39:1219.CrossRefGoogle ScholarPubMed
3. Burnham, JP, Olsen, MA, Stwalley, D, Kwon, JH, Babcock, HM, Kollef, MH. Infectious diseases consultation reduces 30-day and 1-year all-cause mortality for multidrug-resistant organism infections. Open Forum Infect Dis 2018;5(3):ofy026.CrossRefGoogle ScholarPubMed
4. Laboratory detection of extended-spectrum β-lactamases (ESBLs). Centers for Disease Control and Prevention website. https://www.cdc.gov/hai/settings/lab/lab_esbl.html. Published 2010. Accessed May 30, 2018.Google Scholar
Figure 0

Table 1 Factors Associated with 30-Day All-Cause Mortality in a Cox Proportional Hazards Modela

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