Risk factors and prognosis of carbapenem-resistant Klebsiella pneumoniae bloodstream infection in ICU patients: a report of 81 cases

doi:10.16139/j.1007-9610.2023.05.11

Abstract

Abstract:

Objective Comprehensive mortality risk analyses and therapeutic assessment in real-world practice are beneficial to guide individual treatment in patients with Carbapenem-resistant Klebsiella pneumoniae bloodstream infections (CRKP-BSI). Methods Retrospective analysis of the clinical characteristics of 81 CRKP-BSI patients in our intensive care unit from July 2016 to June 2020, to indentify the risk factors of death and treatment effects of different antibiotic regimens. Results In 81 CRKP-BSI cases, the majority source were from abdominal and respiratory, accounting for 56.79% (46 cases) and 22.22% (18 cases), respectively. The 28-day mortality and hospitalization mortality of CRKP-BSI were 54.32% (44 cases) and 65.43% (53 cases). Multivariate regression analysis suggested that biliary tract disease before admission (P=0.026) and increased SOFA score at the onset of BSI (P=0.006) were independent risk factors for 28-day mortality. There was no statistically significant difference in 28-day mortality between the groups of antibiotic treatment based on tigecycline (44 cases) and polymyxin B (26 cases) [56.82% (25/44) vs. 57.69% (15/26), P=0.943]. Patients were evaluated based on their age (≤ 65 years vs. >65 years), gender, body mass index (≤25 kg/m² vs. >25 kg/m²), and APACHE Ⅱ score (≤20 vs. >20), the use of renal replacement therapy and mechanical ventilation, there was no difference in the mortality among each subgroup. Conclusions Biliary tract disease before admission and SOFA score were independent risk factors for 28-day mortality. There was no significant difference outcomes between tigecycline- and polymyxin B-based therapy.

Key words: Carbapenem-resistant Klebsiella pneumoniae, Bloodstream infection, Critically ill patient

CLC Number:

LIU Meng, XU Wen, DAI Yunqi, TAN Ruoming, LIU Jialin, GU Feifei, CHEN Erzhen, WANG Xiaoli, QU Hongping, QIU Yuzhen. Risk factors and prognosis of carbapenem-resistant Klebsiella pneumoniae bloodstream infection in ICU patients: a report of 81 cases[J]. Journal of Surgery Concepts & Practice, 2023, 28(05): 454-462.

Figures/Tables 6

Tab 1

Clinical characteristics and analysis of factors associated with 28-day all-cause mortality of critically ill patients with CRKP-BSI [$\bar{x} \pm s$/M(P25，P75)/n(%)]

Item	Total(n=81)	Non-surviver(n=44)	Surviver(n=37)	t/Z/χ² value	P value
Demographic variable
Age (years)	58.12±17.52	62.73±14.66	52.65±19.20	2.68	0.009^a）
Male sex [n(%)]	63 (77.78)	32(72.72)	31(83.78)	1.42	0.233^b）
BMI (kg/m²)	23.88(21.83, 27.63)	24.79(18.62, 30.96)	23.67(22.07, 27.32)	791	0.827^b）
NRS-2002	6(4, 6)	6(4, 6)	5(4, 6)	675	0.170^b）
Comorbidity
Charlson comorbidity score	2(1,4)	3(1, 4)	2(0, 6)	674	0.178^b）
Diabetes mellitus [n(%)]	24(19.63)	12(27.27)	12(32.43)	0.26	0.612^c）
Chronic renal failure [n(%)]	8(9.88)	3(6.82)	5(13.51)	0.40	0.527^c）
Chronic liver diseases [n(%)]	1(1.23)	1(2.27)	0(0)	-	1^c）
Biliary tract disease [n(%)]	10(12.35)	9(20.45)	1(2.7)	4.33	0.038^c）
Congestive heart failure [n(%)]	2(2.47)	2(4.55)	0(0)	-	0.498^c）
COPD [n(%)]	5(6.17)	3(6.82)	2(4.88)	0	1^c）
Malignancy [n(%)]	13(16.05)	7(15.91)	6(16.22)	0.00	0.97^c）
Immunosupressiono [n(%)]	8(9.88)	3(6.82)	5(13.51)	0.4.	0.527^c）
Health-care exposure before hospitalization
Antibiotic exposure (< 30 d) [n(%)]	53(65.43)	26(59.09)	27(70.97)	1.71	0.191^c）
ICU admission(< 30 d) [n(%)]	31(38.27)	13(29.55)	18(48.65)	3.11	0.078^c）
Surgery(< 30 d) [n(%)]	16(19.75)	7(15.91)	9(24.32)	0.90	0.343^c）
Immunosuppressive therapy (< 3 m) [n(%)]	9(11.11)	3(6.82)	6(16.22)	0.97	0.324^c）
Previous hospitalization (< 12 m) [n(%)]	47(58.02)	26(59.09)	21(56.76)	0.05	0.832^c）
Length of stay before BSI	23.00(13.00, 36.00)	23.50(14.25, 39.50)	23(9.00, 33.50)	755	0.576^b）
Source of infection [n(%)]
Central line	8(9.88)	4(9.09)	4(10.81)	0.00	1^c）
Urinary tract	2(2.47)	1(2.27)	1(2.70)	-	1^c）
Intra-abdominal	46(56.79)	24(54.55)	22(59.46)	0.20	0.657^c）
Respiratory	18(22.22)	11(25.00)	7(18.92)	0.43	0.512^c）
Skin and soft tissue	3(3.70)	2(4.55)	1(2.70)	0.00	1^c）
Cardio-vascular system infection	1(1.23)	1(2.27)	0	-	1^c）
Primary	3(3.70)	1(2.27)	2(5.41)	0.02	0.878^c）
Severity of illness at BSI onset
Biomarker at BSI onset
PCT (ng/L)	2.99(0.77, 7.95)	3.86 (1.70, 7.95)	1.33(0.46, 8.59)	501	0.033^b）
CRP (mg/L)	124.54±83.45	137.65±82.03	112.91±83.10	1.28	0.239^a）
Organ dysfunction at BSI onset
AKI [n(%)]	42(51.85)	29(65.91)	13(35.14)	7.62	0.006^c）
RRT [n(%)]	29(35.80)	20(45.45)	9(24.32)	3.90	0.048^c）
Septic shock [n(%)]	61(75.31)	41(93.18)	20(54.05)	16.55	<0.001^c）
mechancal ventilation [n(%)]	65(80.25)	38(86.36)	27(72.97)	2.27	0.132^c）
APACHE Ⅱ score at BSI onset	24(18, 28)	27(22, 29)	19(14, 26)	426.50	<0.001^b）
SOFA score at BSI onset	8(6, 11)	9(8, 13)	6(3, 8)	360.60	<0.001^b）
PBS	4(2, 5)	4(3, 6)	3(1, 4)	512.50	0.004^b）
Outcomes
Length of hospital stay（d）	55.00(31.00, 86.50)	36.00(25.25, 60.50)	80.00(11.51, 48.50)	299	<0.001^b）
Length of stay in ICU（d）	42.00(24.00, 79.00)	28.50(18.25, 51.25)	65.00(44.00, 102.50)	378.50	<0.001^b）

Tab 1

Tab 2

Tab 3

Tab 4

Comparation of the demographics and clinical characteristics between tigecycline- and polymyxin B-based regimen group [$\bar{x} \pm s$/M(P25，P75)/n(%)]

Item	Tigecycline-based regimens (n=44)	Polymyxin B-based regimens (n=26)	t/Z/χ² value	P value
Demographic variables
Age （years）	55.73 $± 19.49$	64.15 $±$ 14.29	-2.08	0.041^a)
Male sex [n(%)]	39(88.64)	16(61.54)	7.13	0.008^c)
Body mass index (kg/m²)	25.51 $±$ 4.06	23.60 $± 5.85$	1.61	0.112^a）
NRS-2002	5(4, 6)	6(4, 6)	0.25	0.303^b)
Comorbidities
Charlson comorbidity index	2(0, 4)	3(1.75, 4.25)	0.25	0.125^b)
Diabetes mellitus [n(%)]	12(27.27)	8(30.77)	0.1.	0.754^c)
Chronic renal failure [n(%)]	4(9.09)	3(11.54)	0.00	1.0^c)
Chronic liver diseases [n(%)]	0	1(3.85)	-	0.371^c)
Biliary tract disease [n(%)]	4(9.09)	6(23.08)	1.59	0.207^c)
Congestive heart failure [n(%)]	0	2(7.69)	-	0.135^c)
COPD [n(%)]	3(6.82)	1(3.85)	0.00	1.0^c)
Malignancy [n(%)]	6(13.64)	6(23.08)	0.47	0.494^c)
Immunosuppression [n(%)]	1(2.27)	3(11.54)	1.17	0.280^c)
Health-care exposure before hospitalization [n(%)]
Antibiotic exposure (< 30 d)	28(63.64)	18(69.23)	0.23	0.634^c)
ICU admission (< 30 d)	17(38.64)	10(38.46)	0.00	0.988^c)
Surgery (< 30 d)	8(18.18)	6(23.08)	0.25	0.621^c)
Immunosuppressive therapy (< 3 months)	2(4.55)	3(11.54)	0.38	0.537^c)
Previous hospitalization (< 12 months)	29(65.12)	12(46.15)	2.63	0.105^c)
Source of infection [n(%)]
Central line	5(11.36)	2(7.69)	0.01	0.934^c)
Urinary tract	0	1(3.85)	-	0.371^c）
Intra-abdominal	28(63.63)	12(46.15)	2.04	0.153^c)
Respiratory	7(15.91)	9(34.62)	3.24	0.072^c)
Skin and soft tissue	2(4.55)	1(3.85)	0.00	1^c)
Cardio-vascular system infection	1(2.27)	0	-	1^c)
Primary	1(2.27)	1(3.85)	-	1^c)
Severity of illness at BSI onset
Biomarker at BSI onset
PCT (ng/L)	2.55(0.89, 7.95)	3.96(0.81, 14.59)	1.64	0.635^b)
CRP (mg/L)	133.39 $± 84.90$	137.78 $± 81.24$	-0.20	0.842^a)
Organ dysfunction at BSI onset
AKI [n(%)]	24(54.55)	15(57.69)	0.07	0.798^c)
RRT [n(%)]	17(38.63)	10(38.46)	0.00	0.998^c)
Septic shock [n(%)]	36(81.82)	20(76.92)	0.25	0.621^c)
Mechanical ventilation [n(%)]	39(88.64)	20(76.92)	0.92	0.336^c)
APACHE Ⅱ score	24.07 $± 7.41$	23.15 $± 8.56$	0.44	0.663^a)
SOFA score	8.00(6.00, 11.00)	8.00(5.75, 11.25)	0.02	0.864^b)
Pitt bacteremia score	4.00(3.00, 5.00)	4.00(2.75, 6.00)	0.136	0.712^b)
Outcomes
28-day mortality [n(%)]	25(56.82)	15(57.69)	0.01	0.943^c)
In-hospital mortality [n(%)]	29(65.91)	18(69.23)	0.08	0.775^c)
Length of stay（d）	63 $. 00 ± 43.02$	69.88 $± 45.57$	-0.63	0.529^a)
Length of stay before BSI（d）	23.00(12.00, 34.00)	24.50(14.50, 54.50)	0.46	0.429^b)
Length of stay in ICU（d）	41(26, 79)	51(21, 81)	0.25	0.822^b)

Tab 4

Fig 1

Fig 2

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Antimicrobial regimen	Total (n=81)	Death in 28-day	P value
Tigecycline-based regimens	44	25(56.82)	0.715
Polymyxin B-based regimens	26	15(57.69)
Other regimens	11	4 (36.36)
Tigecycline-based regimens	44	25(56.82)
Tigecycline monotherapy	4	4(100)
Tigecycline + Carbapenem	27	15(55.55)
Tigecycline + Amikacin	2	0
Tigecycline + Fosfomycin	1	1(100)
Tigecycline + Sulfamethoxazole	2	1(50)
Tigecycline + Carbapenem + Amikacin	2	1(50)
Tigecycline + Carbapenem + Fosfomycin	3	2(66.67)
Tigecycline + Carbapenem + Sulfamethoxazole	2	0
Tigecycline + Carbapenem + Amikacin + Fosfomycin	1	1(100)
Polymyxin B-based regimens	26	14(53.85)
Polymyxin B monotherapy	1	0
Polymyxin B + Carbapenem	13	8(61.54)
Polymyxin B + Fosfomycin	2	0
Polymyxin B + Tigecycline	4	2(50)
Polymyxin B + Tigecycline + Carbapenem	3	2(66.67)
Polymyxin B + Carbapenem + Fosfomycin	1	1(100)
Polymyxin B + Ceftazidime-Avibactam	2	1(50)
Other regimens	11	4(36.36)
Ceftazidime-Avibactam monotherapy	1	0
Cefoperazone + Fosfomycin	2	0
Carbapenem + Fosfomycin	2	1(50)
Carbapenem + Amikacin	3	2(66.67)
Carbapenem + Sulfamethoxazole	1	0
Ceftazidime-Avibactam + Amikacin	1	1(100)
Cefoperazone-sulbactam + Fosfomycin	1	0