Infection Control & Hospital Epidemiology (2018), 39, 1431–1435 doi:10.1017/ice.2018.254
Original Article
Poor clinical outcomes associated with community-onset urinary tract infections due to extended-spectrum cephalosporin-resistant Enterobacteriaceae
Judith A. Anesi MD1, Ebbing Lautenbach MD, MPH, MSCE1,2,3, Irving Nachamkin DrPH, MPH4, Charles Garrigan MB4, Warren B. Bilker PhD2,3, Jacqueline Omorogbe BS2, Lois Dankwa BA2, Mary K. Wheeler MBE2, Pam Tolomeo
MPH2 and Jennifer H. Han MD, MSCE1,2,3 for the CDC Prevention Epicenters Program 1Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 2Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 3Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania and 4Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
Abstract
Objective: Resistance to extended-spectrum cephalosporins (ESC) among Enterobacteriaceae (EB) is increasingly prevalent. We sought to determine the clinical outcomes associated with community-onset ESC-resistant (ESC-R) EB urinary tract infections (UTIs) in a US health system. Design: Retrospective cohort study. Patients: All patients presenting to the emergency departments (EDs) or outpatient practices with EB UTIs between 2010 and 2013 were included. Exposed patients had ESC-R EB UTIs. Unexposed patients had ESC-susceptible EB UTIs and were matched to exposed subjects 1:1 on study year. Multivariable logistic regression analyses were performed to evaluate the association between ESC-R EB UTI and the outcomes of clinical failure and inappropriate initial antibiotic therapy (IIAT). Results: A total of 302 patients with community-onset EB UTI were included, with 151 exposed and unexposed. On multivariable analyses, UTI due to an ESC-R EB was significantly associated with clinical failure (odds ratio [OR], 7.07; 95% confidence interval [CI], 3.16–15.82; P<.01). Other independent risk factors for clinical failure included infection with Citrobacter spp and need for hemodialysis. UTI due to an ESC-R EB was also significantly associated with IIAT (OR, 4.40; 95% CI, 2.64–7.33; P<.01). Conclusions: Community-onset UTI due to an ESC-R EB organism is significantly associated with clinical failure, which may be due in part to IIAT. Further studies are needed to determine which patients in the community are at high risk for drug-resistant infection to help inform prompt diagnosis and appropriate antibiotic prescribing for ESC-R EB.
(Received 20 June 2018; accepted 16 September 2018; electronically published October 30, 2018)
Antibiotic resistance among gram-negative bacteria continues to emerge. In particular, resistance to extended-spectrum cephalos- porins (ESC) among Enterobacteriaceae (EB) is increasingly prevalent.1–4 Urinary tract infections (UTIs) are the most com- mon bacterial infection among adults in the community,5 and data have demonstrated marked increases in bacterial resistance to first-line antibiotics used to treat UTIs in ambulatory settings.6 In particular, reports of ESC-resistant (ESC-R) EB UTIs in the outpatient setting have been increasing.7–11 Relatively little is known about the outcomes associated with
such community-onset ESC-R EB UTIs. Prior studies have shown that ESC-R EB infections among hospitalized patients are asso- ciated with increased morbidity, mortality, and healthcare
Author for correspondence: Judith A. Anesi, MD, Division of Infectious Diseases,
Department of Medicine, Hospital of the University of Pennsylvania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104. Email:
judith.anesi@uphs.upenn.edu
Cite this article: Anesi J, et al. (2018). Poor clinical outcomes associated with community-onset urinary tract infections due to extended-spectrum cephalosporin- resistant Enterobacteriaceae. Infection Control & Hospital Epidemiology 2018, 39, 1431– 1435. doi: 10.1017/ice.2018.254
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
Materials and Methods Study design and setting
A retrospective cohort study was performed at two emergency departments (EDs) and a network of outpatient practices within
costs.12,13 Community-onset bacteremic UTIs due to ESC-R EB have been associated with delay in appropriate antibiotics and increased mortality.14–17 In a retrospective study of 120 patients that included both community- and hospital-onset UTIs, the only independent predictor of clinical failure was ESBL production.18 However, few prior studies have evaluated the outcomes associated with the more common nonbacteremic community-onset ESC-R EB UTI. Therefore, in this study, we sought to determine the association between community-onset ESC-R EB UTI and clinical failure. Furthermore, we evaluated whether community-onset ESC- R EB UTI was associated with a delay in the initiation of appro- priate antibiotics and whether this impacted the clinical outcome.
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