model to predict mdr-gnb colonization and infection 1219


table 1. Bacteriology and Culture Sites of Multidrug-Resistant Gram-Negative Bacteria (MDR-GNB) Isolates MDR-GNB Colonization


First Stage (n =122)a


Bacterial isolate Escherichia coli


Acinetobacter species Pseudomonas aeruginosa Klebsiella pneumoniae Enterobacter species Citrobacter species Proteus mirabilis Other bacteria


Clinical culture site Sputum Urine Blood


Wound Other site


Surveillance culture site Throat swab Urine


Nasal swab Wound


No. 44 32 22 21 14 7 5 8


36 30 8 3 4


50 28 23 11


% 36.1


26.2c 18.0 17.2


11.5e 6.6h


29.5 24.6 6.6 2.5 3.3


Second Stage (n=47)b


No. 8


11 8


18 1


4 4


% 17.0


23.4d 17.0 38.3


2.1f


5.7g 00 4.1


13 23 7 5 4


8.5 8.5i


27.7 48.9 14.9 10.6 8.5


41.0 …… 23.0 …… 18.9 …… 9.0 ……


aA total of 153 multidrug-resistant isolates were identified. bA total of 54 multidrug-resistant isolates were identified. cIncludes Acinetobacter baumannii (31) and A. lwoffii (1). dAll were Acinetobacter baumannii. eIncludes Enterobacter cloacae (10) and E. aerogenes (4). fEnterobacter cloacae. gIncludes Citrobacter freundii (4) and C. koseri (3). hIncludes Serratia marcescens (5), Morganella morganii (2), and Providencia stuartii (1). iIncludes Serratia marcescens (1), Morganella morganii (1), Chryseobacterium indologenes (1) and Elizabethkingia meningo- septica (1).


Many variables were found to be associated with coloniza-


tion of patients withMDR-GNB by a univariate analysis of the derivation set data, including patient age>70 years, LTCF residence, hospital discharge in the previous 1 month, inten- sive care unit admission in the previous 3 months, exposure to any antibiotics for>48 hours in the previous 3 months, a history of cerebrovascular accident (CVA), the presence of pressure sores, and the presence of a Foley catheter. The multivariate logistic regression model, which incorporated all potential predictors from the univariate analysis, identified 5 independent predictors of MDR-GNB colonization: age>70 years, LTCF residence, history of CVA, hospital discharge in the previous month, and recent exposure to any antibiotics for>48 hours in the previous 3 months (Table 3). The Hos- mer–Lemeshow goodness-of-fit statistic was 0.72, and the area under the ROC curve (AUC) of the model was 0.75 (95% confidence interval [CI], 0.69–0.81). When applied to the validation set, the model maintained its predictive perfor- mance: AUC, 0.80 (95% CI, 0.73–0.87). The point values assigned to each predictor within the COP model are shown in Table 3. These point values were used to


calculate the overall score of the risk of MDR-GNB coloniza- tion for each patient. A complete summary of the diagnostic accuracy of the COP model for the various score cutoffs is detailed in Online Appendix Table A. The Youden index indicated that the COP model performed best at a cutoff of ≥4 points, with an overall diagnostic sensitivity of 0.57 and spe- cificity of 0.85 at this cutoff value. The prevalences of MDR- GNB colonization among the 995 study patients at low risk (score<4) and high risk (score ≥4) were 6.7% (53 of 794) and 34.3% (69 of 201), respectively (Figure 1).


Usefulness of COP Model in MDR-GNB Infection Risk Stratification


Clinical data of 998 patients enrolled in the second stage of this study were used to evaluate the usefulness of the COP model in stratifying ED patients at risk of subsequent MDR-GNB infection during hospitalization. We identified significant dif- ferences in the clinical characteristics of the second-stage study patients compared to those of the first-stage study patients. They were older, had more healthcare-associated or antibiotic


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