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Table 2. Bivariable Analyses Comparing Clinical Outcomes of Resistant Case Patients, Susceptible Case Patients, and Uninfected Control Patients (n = 85 patients in each group).
Parameter
Hours to appropriate therapy, median (range)
≥48 h DAAT
Clinical outcomes In hospital mortality 14-d mortality 90-d mortality
CRPA No. (%)a
CSPA No. (%)a
Time to appropriate antimicrobial therapy parameters 31.3 (0–121) 7 (0–118) 39 (58.2) 21 (30.4)
45 (52.9) 46 (54.1) 24 (28.2) 36 (42.4) 28 (32.9)
51 (60) 52 (61.2) 29 (34.1)
Among survivors of the index hospitalization only Functional deterioration
Discharged to LTCF after being admitted from home
Invasive procedure or surgery in the following 3 mob
Length of stay, median d (range) 18 (46.2) 20 (51.3) 18 (29.5) 2.5 (1.4–5)
2 (2.4) 33.3 (7.1–100) 2.9 (1.6–5.3)
2.1 (0.9–5) 19 (65.5) 16 (44.4) 10 (19.2) 10 (2.9–20) CDI isolation in the following 3 mo 1 (1.2) 2 (2.4) 1 (1.2) 31 (36.9) 29 (34.5) 52 (61.2) 37 (0–193) 35 (0–168) 21 (0–99) .001 .01 3.3 (1.7–5) 3.3 (1.7–5)
<.001 20.0 (4.8–100) <.001 3.3 (1.7–5.1) <.001
.09 <.001
1.0 (0.06–16.66) >.99 .02
0.4 (0.2–0.7) <.001
2.5 (1.1–5.0) 3.3 (1.4–10)
.03 .01
2.0 (0.2–25) >.99 0.3 (0.2–0.6)
.001 >0.99 (0.5–1.7) 1.4 (0.8–2.5) 0.9 (0.5–1.7)
0.8 (0.3–2) 2.5 (0.8–5)
.001 <.001
Clostridium difficile infection. Significant associations are highlighted in bold. aValid percent: count divided by the total number of valid (ie, nonmissing) observations. bExamples of invasive procedure other than surgery include endoscopy, percutaneous procedure, central line, urinary catheter, and drain insertion.
We conducted 2 multivariable risk factor analyses: resistant
cases versus controls and susceptible cases versus controls. The independent predictors of CRPA were ischemic heart disease (aOR, 0.17; P = .02), recent (3 months) exposure to carbapenems (aOR, 17.4; P = .001), and rapidly fatal McCabe9 condition (aOR, 12.1; P = .001). Independent predictors of CSPA were advanced age (P = .02), ischemic heart disease (aOR, 0.13; P = .005), and recent invasive procedure (aOR, 24; P < .001). Independent predictors associated with CRPA but not CSPA infection were recent expo- sure to carbapenems and a rapidly fatal McCabe score.9
Clinical outcomes of CRPA BSI
Of the 255 patients included in this study, 115 patients (45.1%) died during their index hospitalization, 66 patients (25.9%) died within 14 days (primary outcome), and 132 patients (51.8%) died within 90 days. Of patients who survived the hospitalization, the median duration of stay was 17 days (range, 0–149 days); 56 patients (40.3%) experienced functional deterioration,7 and 45 patients (38.5%) were discharged to a long-term care facility (LTCF) after being admitted from home. Patients with CRPA or CSPA BSIs had significantly worse clinical outcomes compared to uninfected controls (Table 2). Clinical outcomes were similar between CRPA and CSPA cases. Time to initiation of appropriate therapy was significantly prolonged among CRPA BSIs compared to CSPA BSIs (Table 2). Multivariable models were calculated for 2 clinical outcomes: 14-day mortality and discharge to an LTCF (Table 2).
Discussion
Debate continues as to whether the associations between poor clinical outcomes and resistance are due to DAAT or to inherent properties of the resistance determinant of the offending strain.1 This study addressed methodological limitations from prior stu- dies evaluated CRPA infections and clinical outcomes. This investigation confirmed that DAAT impacts outcomes of
Independent factors associated with 14-day mortality were time to appropriate antimicrobial therapy (P = .008), malignancy (aOR, 4.1; 95% confidence interval [CI], 1.5–11.5; P = .007), rapidly fatal McCabe score (aOR, 3.7; 95% CI, 1.1–12.1; P = .03),9 and a Pitt bacteremia score ≥4 (aOR, 1.3; 95% CI, 1.1– 1.5; P = .004).10 Independent factors associated with discharge to an LTCF were impaired cognition at baseline (aOR, 14.7; 95% CI, 1.2–176; P = .03), ICU stay during current hospitalization (aOR, 24.3; 95% CI, 2.2–266; P = .009), and Pitt bacteremia score ≥4 (aOR, 1.8; 95% CI, 1.03–3.1; P = .04).10 Carbapenem resistance was not associated with these outcomes.
0.5 (0.1–5) 1.1 (0.6–2)
.034 .001
.90 .20 .90
.70 .09
>.99 .70
.932 Note. CRPA, carbapenem-resistant Pseudomonas aeruginosa; CSPA, carbapenem-susceptible P. aeruginosa; OR, odds ratio; CI, confidence interval; LTCF, long-term care facility; CDI,
Uninfected Controls No. (%)a
CRPA vs Uninfected OR
(95% CI) P Value
CSPA vs Uninfected CRPA vs CSPA OR
(95% CI) P Value OR (95% CI) P Value
patients with multidrug-resistant organism (MDRO) infections.1 This impact has been demonstrated in the past with Acinetobacter baumannii, carbapenem-resistant enterobacteriaceae (CRE), vancomycin-resistant enterococci (VRE), and methicillin- resistant Staphylococcus aureus (MRSA).1 There is an urgent need to develop genuine measures to shorten DAAT (eg, via use of rapid diagnostics, efficacious predictive tools) to improve the outcomes of MDRO infections.1
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