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Imipenem Resistance in Pseudomonas aeruginosa ... - CCIH

Imipenem Resistance in Pseudomonas aeruginosa ... - CCIH

Imipenem Resistance in Pseudomonas aeruginosa ... -

infection control and hospital epidemiology january 2010, vol. 31, no. 1 original article Imipenem Resistance in Pseudomonas aeruginosa: Emergence, Epidemiology, and Impact on Clinical and Economic Outcomes Ebbing Lautenbach, MD, MPH, MSCE; Marie Synnestvedt, PhD; Mark G. Weiner, MD; Warren B. Bilker, PhD; Lien Vo, PharmD; Jeff Schein, DrPH, MPH; Myoung Kim, PhD, MBA background. Pseudomonas aeruginosa is one of the most common gram-negative hospital-acquired pathogens. Resistance of this organism to imipenem complicates treatment. objective. To elucidate the risk factors for imipenem-resistant P. aeruginosa (IRPA) infection or colonization and to identify the effect of resistance on clinical and economic outcomes. methods. Longitudinal trends in prevalence of IRPA from 2 centers were characterized during the period from 1989 through 2006. For P. aeruginosa isolates obtained during the period from 2001 through 2006, a case-control study was conducted to investigate the association between prior carbapenem use and IRPA infection or colonization, and a cohort study was performed to identify the effect of IRPA infection or colonization on mortality, length of stay after culture, and hospital cost after culture. results. From 1989 through 2006, the proportion of P. aeruginosa isolates demonstrating resistance to imipenem increased from 13% to 20% ( P ! .001, trend). During the period from 2001 through 2006, there were 2,542 unique patients with P. aeruginosa isolates, and 253 (10.0%) had IRPA isolates. Prior carbapenem use was independently associated with IRPA infection or colonization (adjusted odds ratio [OR], 7.92 [95% confidence interval {CI}, 4.78–13.11]). Patients with an IRPA isolate recovered had higher in-hospital mortality than did patients with an imipenem-susceptible P. aeruginosa isolate (17.4% vs 13.4%; P p .01 ). IRPA infection or colonization was an independent risk factor for mortality among patients with isolates recovered from blood (adjusted OR, 5.43 [95% CI, 1.72–17.10]; P p .004) but not among patients with isolates recovered from other anatomic sites (adjusted OR, 0.78 [95% CI, 0.51–1.21]; P p .27). Isolation of IRPA was associated with longer hospital stay after culture ( P ! .001) and greater hospital cost after culture ( P ! .001) than was isolation of an imipenem-susceptible strain. In multivariable analysis, IRPA infection or colonization remained an independent risk factor for both longer hospital stay after culture (coefficient, 0.20 [95% CI, 0.04–0.36]; P p .02) and greater hospital cost after culture (coefficient, 0.30 [95% CI, 0.06–0.54]; P p .02). conclusions. The prevalence of IRPA infection or colonization has increased significantly, with important implications for both clinical and economic outcomes. Interventions to curb this continued increase and strategies to optimize therapy are urgently needed. Infect Control Hosp Epidemiol 2010; 31:47-53 Pseudomonas aeruginosa is among the most common gramnegative hospital-acquired pathogens. 1,2 The importance of P. aeruginosa as a nosocomial pathogen is evidenced by a mortality rate of up to 50% for bloodstream infections due to this pathogen. 3 The importance of thoughtful antibiotic selection in the empirical and definitive treatment of infections due to P. aeruginosa is supported by the possible association between inadequate therapy and mortality. 4,5 While carbapenem antibiotics (eg, imipenem and meropenem) remain among the most consistently effective agents in the treatment of P. aeruginosa infections, decisions regarding antibiotic therapy have become increasingly compli- cated as a result of continued emergence of antibiotic resistance. 6 Imipenem resistance in P. aeruginosa has increased steadily in recent years and is often also associated with resistance to other antibiotics. 2,7 Given these concerns, the identification of potentially modifiable risk factors for imipenem-resistant P. aeruginosa (IRPA) infection or colonization is critical. Furthermore, the clinical and economic effect of IRPA infection or colonization must be clearly defined. Elucidation of the epidemiological characteristics of IRPA is vital if efforts are to be designed to curb recent increases in antibiotic resistance. Furthermore, identifying the effect of resistance on clinical and economic From the Divisions of Infectious Diseases (E.L.) and General Internal Medicine (M.G.W.) of the Department of Medicine, the Department of Biostatistics and Epidemiology (E.L., W.B.B.), the Center for Clinical Epidemiology and Biostatistics (E.L., W.B.B.), and the Center for Education and Research on Therapeutics (E.L., M.S., M.G.W., W.B.B.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and Ortho-McNeil Janssen Scientific Affairs, Raritan, New Jersey (L.V., J.S., M.K.). Received June 9, 2009; accepted August 3, 2009; electronically published December 1, 2009. � 2009 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3101-0008$15.00. DOI: 10.1086/649021

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