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The incidence of infections from extended-spectrum β-lactamase (ESBL)–producing Enterobacterales (ESBL-E) is increasing in the United States. We describe the epidemiology of ESBL-E at 5 Emerging Infections Program (EIP) sites.
During October–December 2017, we piloted active laboratory- and population-based (New York, New Mexico, Tennessee) or sentinel (Colorado, Georgia) ESBL-E surveillance. An incident case was the first isolation from normally sterile body sites or urine of Escherichia coli or Klebsiella pneumoniae/oxytoca resistant to ≥1 extended-spectrum cephalosporin and nonresistant to all carbapenems tested at a clinical laboratory from a surveillance area resident in a 30-day period. Demographic and clinical data were obtained from medical records. The Centers for Disease Control and Prevention (CDC) performed reference antimicrobial susceptibility testing and whole-genome sequencing on a convenience sample of case isolates.
We identified 884 incident cases. The estimated annual incidence in sites conducting population-based surveillance was 199.7 per 100,000 population. Overall, 800 isolates (96%) were from urine, and 790 (89%) were E. coli. Also, 393 cases (47%) were community-associated. Among 136 isolates (15%) tested at the CDC, 122 (90%) met the surveillance definition phenotype; 114 (93%) of 122 were shown to be ESBL producers by clavulanate testing. In total, 111 (97%) of confirmed ESBL producers harbored a blaCTX-M gene. Among ESBL-producing E. coli isolates, 52 (54%) were ST131; 44% of these cases were community associated.
The burden of ESBL-E was high across surveillance sites, with nearly half of cases acquired in the community. EIP has implemented ongoing ESBL-E surveillance to inform prevention efforts, particularly in the community and to watch for the emergence of new ESBL-E strains.
Background: Candidemia is associated with high morbidity and mortality. Although risk factors for candidemia and other bloodstream infections (BSIs) overlap, little is known about patient characteristics and the outcomes of polymicrobial infections. We used data from the CDC Emerging Infections Program (EIP) candidemia surveillance to describe polymicrobial candidemia infections and to assess clinical differences compared with Candida-only BSIs. Methods: During January 2017–December 2017 active, population-based candidemia surveillance was conducted in 45 counties in 9 states covering ~6% of the US population through the CDC EIP. A case was defined as a blood culture with Candida spp in a surveillance-area resident; a blood culture >30 days from the initial culture was considered a second case. Demographic and clinical characteristics were abstracted from medical records by trained EIP staff. We examined characteristics of polymicrobial cases, in which Candida and ≥1 non-Candida organism were isolated from a blood specimen on the same day, and compared these to Candida-only cases using logistic regression or t tests using SAS v 9.4 software. Results: Of the 1,221 candidemia cases identified during 2017, 215 (10.2%) were polymicrobial. Among polymicrobial cases, 50 (23%) involved ≥3 organisms. The most common non-Candida organisms were Staphylococcus epidermidis (n = 30, 14%), Enterococcus faecalis (n = 26, 12%), Enterococcus faecium (n = 17, 8%), and Staphylococcus aureus, Klebsiella pneumoniae, and Stenotrophomonas maltophilia (n = 15 each, 7%). Patients with polymicrobial cases were significantly younger than those with Candida-only cases (54.3 vs 60.7 years; P < .0004). Healthcare exposures commonly associated with candidemia like total parenteral nutrition (relative risk [RR], 0.82; 95% CI, 0.60–1.13) and surgery (RR, 0.99; 95% CI, 0.77–1.29) were similar between the 2 groups. Polymicrobial cases had shorter median time from admission to positive culture (1 vs 4 days, P < .001), were more commonly associated with injection drug use (RR, 1.95; 95% CI, 1.46–2.61), and were more likely to be community onset-healthcare associated (RR, 1.91; 95% CI, 1.50–2.44). Polymicrobial cases were associated with shorter hospitalization (14 vs 17 days; P = .031), less ICU care (RR, 0.7; 95% CI, 0.51–0.83), and lower mortality (RR, 0.7; 95% CI, 0.50–0.92). Conclusions: One in 10 candidemia cases were polymicrobial, with nearly one-quarter of those involving ≥3 organisms. Lower mortality among polymicrobial cases is surprising but may reflect the younger age and lower severity of infection of this population. Greater injection drug use, central venous catheter use, and long-term care exposures among polymicrobial cases suggest that injection or catheter practices play a role in these infections and may guide prevention opportunities.
OBJECTIVES/SPECIFIC AIMS: To describe the epidemiology of patients with carbapenem-resistant Enterobacteriaceae (CRE) bacteriuria in metropolitan Atlanta, GA and to identify risk factors associated with progression to an invasive CRE infection. We hypothesize that having an indwelling urinary catheter increases the risk of progression. METHODS/STUDY POPULATION: The Georgia Emerging Infections Program (EIP) performs active population- and laboratory-based surveillance to identify CRE isolated from a sterile site (e.g. blood) or urine among patients who reside in the 8-county metropolitan Atlanta area (population ~4 million). The Georgia EIP performs a chart review of each case to extract data on demographics, culture location, resistance patterns, healthcare exposures, and other underlying risk factors. We used a retrospective cohort study design to include all Georgia EIP cases with Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter cloacae, or Klebsiella (formerly Enterobacter) aerogenes, adapting the current EIP definition of resistance to only include isolates resistant to meropenem, imipenem or doripenem (minimum inhibitory concentration ≥ 4) first identified in a urine culture from 8/1/2011 to 7/31/2017. Patients with CRE identified in a sterile site culture prior to a urine culture will be excluded. Within this cohort, we will identify which patients had a subsequent similar CRE isolate identified from a sterile site between one day and one year after the original urine culture was identified (termed “progression”). CRE isolates will be defined as similar if they are the same species and have the same carbapenem susceptibility pattern. Univariable analyses using T-tests or other nonparametric tests for continuous variables, and Chi-square tests (or Fisher’s exact tests as appropriate) for categorical variables will compare patient demographics, comorbidities and presence of invasive devices including urinary catheters between patients who had progression to an invasive infection and those who did not have progression. Covariates with a p-value of < 0.2 will be eligible for inclusion in the multivariable logistic regression model with progression to invasive infection as the primary outcome. All statistical analyses will be done in SAS 9.4. RESULTS/ANTICIPATED RESULTS: From 8/1/2011 to 7/31/2017 we have preliminarily identified 546 patients with CRE first identified in urine, representing an annual incidence rate of 1.1 cases per 100,000 population. Most cases were K. pneumoniae (352, 64%), followed by E. coli (117, 21%), E. cloacae (48, 9%), K. aerogenes (18, 3%), and K. oxytoca (11, 2%). The mean patient age was 64 +/− 18 years and the majority (308, 56%) were female. Clinical characterization through chart review was available for 507 patients. The majority of the patients were black (301, 59%), followed by white (166, 33%), Asian (12, 2%), and other or unknown race (28, 6%). 466 (92%) patients had at least one underlying comorbid condition with a median Charlson Comorbidity Index of 3 (IQR 1-5). 460 (91%) infections were considered healthcare-associated (366 community-onset and 94 hospital-onset), while 44 (9%) were community-associated. 279 (55%) patients had a urinary catheter within the two days prior to the CRE culture. The analysis of patients who progress to an invasive CRE infection, including the results of the univariable and multivariable analyses assessing risk factors for progression is in progress and will be reported in the future. DISCUSSION/SIGNIFICANCE OF IMPACT: In metropolitan Atlanta, the annual incidence of CRE first isolated in urine was estimated to be 1.1 cases per 100,000 population between 2011 and 2017, with the majority of the cases being K. pneumoniae. Most patients had prior healthcare exposure and more than 50% of the patients had a urinary catheter. Our anticipated results will identify risk factors associated with progression from CRE bacteriuria to an invasive infection with a specific focus on having a urinary catheter, as this is a potentially modifiable characteristic that could be a target of future interventions.
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