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Friday, March 19, 2010
Grand Hall (Hyatt Regency Atlanta)
Background: Pseudo is a common HAI pathogen associated with significant morbidity and mortality. Of particular concern has been multidrug-resistant pseudo as therapeutic options are limited.
Objective: We describe the epidemiology of pseudo HAI at our hospital, including the impact of antibiotic resistance (R) and risks for mortality.
Methods: We conducted a retrospective cohort study of patients with pseudo HAI from 1/1998-6/2008. We recorded patient data, type of HAI (hospital-acquired pneumonia (HAP), bloodstream infection (BSI), or surgical site infection (SSI), LOS, ICU care, mortality, and R to antipseudomonal (AP) cephalosporins, aminoglycosides (AG), AP penicillins, fluoroquinolones (FQ), aztreonam, and carbapenems. Mortality was defined as death during the hospitalization when the patient suffered the HAI. NHSN definitions were used for HAI. Logistic regression was used to assess for significant risks for mortality.
Results: 340 pseudo HAI were identified, 165 (48.5%) were HAP, 101 (29.7%) SSI, and 52 (15.3%) BSI. Overall 90 (26.5%) patients died, 64 (38.8%) with HAP, 17 (32.7%) with BSI, and 5 (5%) with SSI. Compared to SSI, those with pseudo HAP or BSI had significantly higher mortality (OR 12.17 and OR 9.33, both p<0.0001, respectively). There was no significant change in overall mortality of those with pseudo HAI over the study period (32.8% vs. 24.1%, p=0.16). 133 (39.1%) patients had a polymicrobial HAI where pseudo was present most commonly with other gram-negatives and staph species. 19.9% of pseudo HAI isolates were R to AP cephalosporins (mortality 34.4%), 19.9% were R to AG (mortality 35%), 20.7% were R to AP penicillins (mortality 41.3%), 18.1% were R to FQ (mortality 30.9%), 40% were R to aztreonam (mortality 28.8%), and 15% were R to carbapenems (mortality 48.9%). 15.5% of isolates were R to 3 or more classes of antibiotics (mortality 41.7%). After univariate analysis, risks for mortality among those with pseudo HAI were; HAP (OR 3.67, p<0.0001), developing infection in the ICU (OR 3.95, p<0.0001), R to AP penicillins (OR 2.26, p=0.006), R to carbapenems (OR 3.29, p=0.0004), and R to 3 or more classes of antibiotics (OR 2.23, p=0.01). After multivariate analysis, HAP (OR 2.20 95%CI 1.13-4.30, p=0.02), and R to carbapenems (OR 2.42 95%CI 1.10-5.31, p=0.03) were independently associated with increased risk for mortality.
Conclusions: Over the past decade, mortality associated with pseudo HAI has remained high at our hospital. The majority of pseudo HAI were HAP and many were polymicrobial in nature, a fact which should be considered for empiric therapy. HAP as well as R to carbapenems were independently associated with increased mortality among patients with pseudo HAI; however resistance to 3 or more classes of antibiotics, what most would consider a multidrug-resistant pseudo, was not.
Objective: We describe the epidemiology of pseudo HAI at our hospital, including the impact of antibiotic resistance (R) and risks for mortality.
Methods: We conducted a retrospective cohort study of patients with pseudo HAI from 1/1998-6/2008. We recorded patient data, type of HAI (hospital-acquired pneumonia (HAP), bloodstream infection (BSI), or surgical site infection (SSI), LOS, ICU care, mortality, and R to antipseudomonal (AP) cephalosporins, aminoglycosides (AG), AP penicillins, fluoroquinolones (FQ), aztreonam, and carbapenems. Mortality was defined as death during the hospitalization when the patient suffered the HAI. NHSN definitions were used for HAI. Logistic regression was used to assess for significant risks for mortality.
Results: 340 pseudo HAI were identified, 165 (48.5%) were HAP, 101 (29.7%) SSI, and 52 (15.3%) BSI. Overall 90 (26.5%) patients died, 64 (38.8%) with HAP, 17 (32.7%) with BSI, and 5 (5%) with SSI. Compared to SSI, those with pseudo HAP or BSI had significantly higher mortality (OR 12.17 and OR 9.33, both p<0.0001, respectively). There was no significant change in overall mortality of those with pseudo HAI over the study period (32.8% vs. 24.1%, p=0.16). 133 (39.1%) patients had a polymicrobial HAI where pseudo was present most commonly with other gram-negatives and staph species. 19.9% of pseudo HAI isolates were R to AP cephalosporins (mortality 34.4%), 19.9% were R to AG (mortality 35%), 20.7% were R to AP penicillins (mortality 41.3%), 18.1% were R to FQ (mortality 30.9%), 40% were R to aztreonam (mortality 28.8%), and 15% were R to carbapenems (mortality 48.9%). 15.5% of isolates were R to 3 or more classes of antibiotics (mortality 41.7%). After univariate analysis, risks for mortality among those with pseudo HAI were; HAP (OR 3.67, p<0.0001), developing infection in the ICU (OR 3.95, p<0.0001), R to AP penicillins (OR 2.26, p=0.006), R to carbapenems (OR 3.29, p=0.0004), and R to 3 or more classes of antibiotics (OR 2.23, p=0.01). After multivariate analysis, HAP (OR 2.20 95%CI 1.13-4.30, p=0.02), and R to carbapenems (OR 2.42 95%CI 1.10-5.31, p=0.03) were independently associated with increased risk for mortality.
Conclusions: Over the past decade, mortality associated with pseudo HAI has remained high at our hospital. The majority of pseudo HAI were HAP and many were polymicrobial in nature, a fact which should be considered for empiric therapy. HAP as well as R to carbapenems were independently associated with increased mortality among patients with pseudo HAI; however resistance to 3 or more classes of antibiotics, what most would consider a multidrug-resistant pseudo, was not.