1210 infection control & hospital epidemiology october 2017, vol. 38, no. 10
trends of ESBL-E. coli or ESBL-Klebsiella infections in the United States from 2000 to 2015.
methods Search Strategy
MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index to Nursing and AlliedHealth Literature via the Elton Bryson Stephens Company (EBSCO), Scopus, National Health Service Economic EvaluationDatabase andWebof Science were searched by a health sciences librarian to identify papers published from January 2000 to July 2014 for articles pertaining to the incidence of ESBL-E. coli or ESBL-Klebsiella infections. The searches were rerun in August of 2015 to identify studies published in the interim. The librarian used terms associated with ESBL; created a filter for incidence, prevalence, and mortality using a pre-established incidence/prevalence search filter (http://
www.systematicreviewsjournal.com/content/2/1/68); and used a pre-established filter to identify economic studies (http://www.
cadth.ca/media/pdf/H0490_Search_Filters_for_Economic_ Evaluations_mg_e.pdf). A list of all search terms is provided in Online Supplemental Appendix 1. Additionally, reference lists from retrieved articles and reviews were examined for relevant studies that were not identified in the initial literature searches.
Inclusion and Exclusion Criteria
Included studies provided information on the incidence of ESBL-E. coli or ESBL-Klebsiella infections published between January 2000 and August 2015 and included the year 2000 or later within their study period. Only multicenter studies (≥2 centers) were included to accurately determine the incidence of ESBL infections within the US population because single-center studies were more likely to represent outbreaks. Studies that provided the number of patients with an ESBL infection and a denominator that included both infected and uninfected patients such as patient days, device days, number of admissions, or number of discharges were included. Studies that provided denominators that only included patients who were infected with non-ESBL organisms were excluded. Additionally, articles were excluded that were not written in English, contained duplicated data, or pertained to ESBL organisms from food, animals, or the environment. Institutional review board approval was not required for this systematic literature review.
Data Extraction and Quality Assessment
Titles, abstracts, and manuscripts were screened by 1 investigator (J.M. or V.C.) for inclusion in the systematic literature review. Moreover, 2 investigators independently abstracted data for included studies. Disagreements were reexamined by both investigators and were resolved by consensus. Reviewers abstracted data on study design, study population, year, number of patients, description of denominator, definition of ESBL, organism examined, inclusion and exclusion criteria, and an
assessment of the potential risk of bias for cohort studies using the Newcastle Ottawa score (Online Supplemental Appendix 2).16
results Article Review
Among the 51,419 studies identified for possible inclusion in the systematic review, 605 were further assessed through manuscript
review.Most studies did not meet the inclusion criteria based on the title or abstract of the study. Finally, 9 studies were included, and 596 studies were excluded (Figure 1). Table 1 provides a summary of the 9 included studies.17–25
Among the 9 studies, 7 were observational studies and 2 were interventional studies. The interventions included screening urine cultures with E. coli or Klebsiella for ESBL18 and restricting the use of ceftazidime and ceftriaxone.22 Furthermore, 6 studies evaluated the incidence of ESBL-producing E. coli and Klebsiella among hospital-onset infections, and 2 studies evaluated the incidence among community-onset infections.
Incidence of ESBL-Producing E. coli and Klebsiella Infections Among All Patients
Incidence rates varied by year, population, and denominator (ie, patient days, device days, discharges, admissions, infants, and person years).Overall, from 1997 to 2011, incidence rates ranged from 0 to 51 cases per 10,000 admissions. During 1999–2006, incidence rates increased from 8.55 to 16.64 cases for ESBL- Klebsiella infections per 10,000 discharges (P<0.05) among patients admitted to 15 hospitals in Brooklyn, New York.20 Throughout 2005–2009, the incidence rate of ESBL-E. coli infections increased from5.82 to 21.53 cases per 100,000 person years within Olmsted County,Minnesota.25 From 2005 to 2008,
figure 1. Flow diagram of searched studies.
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