Infections with blaKPC-2-producing Klebsiella pneumoniae in renal transplant patients: a retrospective study

Burden and Management of Multi-Drug Resistant Organism Infections in Solid Organ Transplant Recipients Across the World: A Narrative Review

Solid organ transplant (SOT) recipients are particularly susceptible to infections caused by multidrug-resistant organisms (MDRO) and are often the first to be affected by an emerging resistant pathogen. Unfortunately, their prevalence and impact on morbidity and mortality according to the type of graft is not systematically reported from high-as well as from low and middle-income countries (HIC and LMIC). Thus, epidemiology on MDRO in SOT recipients could be subjected to reporting bias. In addition, screening practices and diagnostic resources may vary between countries, as well as the availability of new drugs. In this review, we aimed to depict the burden of main Gram-negative MDRO in SOT patients across HIC and LMIC and to provide an overview of current diagnostic and therapeutic resources.

Doxycycline for Multidrug-Resistant Gram-Negative Bacterial Infection Treatment: A Scoping Review

Introduction

Multidrug-resistant bacterial infections limit available therapeutic options. Doxycycline is an old antibiotic from the tetracycline class that exhibits a wide antibacterial action, including Gram-negative bacteria (GNB), and could be an alternative for the treatment of multidrug-resistant (MDR) Enterobacteriaceae. The study aimed to systematically identify, evaluate, and summarize the results of studies related to outcomes of treatments for MDR-GNB infections in patients treated with doxycycline.

Methods

This review was conducted in four databases during weeks 41-52 of 2022: PubMed, Medline, Scopus, and Web of Science, from the earliest year available on each database to December 2022. Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were followed in conducting this study, and PICO was used for the research question of this review.

Results

This scoping review found 8 retrospective studies that included 59 patients. Of these, 69% were treated for ventilator-associated pneumonia (VAP), 27% for urinary tract infections, 2% for bloodstream infections, and 2% for wound infections, both of which were associated with VAP. The usual dosage of doxycycline was 100 mg intravenously or orally. Clinical and microbiologic improvements were achieved in 81.3% and 87% of all patients, respectively. The mortality rate was 17.3% and was exclusively due to VAP.

Conclusions

Doxycycline showed promising results in this review; however, randomized clinical trials or prospective cohorts are recommended to demonstrate the efficacy of doxycycline in the treatment of MDR infections with GNB.

Multidrug-resistant Enterobacterales infections in abdominal solid organ transplantation

BACKGROUND

Transplant recipients are highly susceptible to multidrug-resistant (MDR) related infections. The lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases.

OBJECTIVES

In this review, we present the current state of knowledge concerning multidrug-resistant Gram negative bacilli's risk management in the care of solid-organ transplant recipients and suggest control strategies.

SOURCES

We searched for studies treating MDR g-negative bacilli related infections in the renal and hepatic transplant patient population. We included randomized and observational studies.

CONTENT

Solid-organ transplant is the best therapeutic option for patients diagnosed with end-stage organ disease. While the incidence of opportunistic infections is decreasing due to better prevention, the burden of "classical" infections related to MDR bacteria especially related to Gram-negative bacteria is constantly increasing. Over the last two decades, various MDR pathogens have emerged as a relevant cause of infection in this specific population associated with significant mortality. Several factors related to the management of transplant donor candidates and recipients increase the risk of MDR infections in transplant recipients. The awareness of this high susceptibility of transplant recipients to MDR-related infections challenges the choice of empirical therapy, while its appropriateness can only be validated a posteriori. Indeed, the lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases.

IMPLICATIONS

Multidrug-resistant Gram-negative bacteria are associated with high morbidity and mortality in solid organ transplant recipients. It seems important to identify patients at risk of colonization/MDR bacteria to evaluate strategies to limit the risk of secondary infections and to minimize the inappropriate use of broad-spectrum antibiotics.

Carbapenem-resistant Enterobacteriaceae among kidney transplant recipients - insights on the risk of acquisition and CRE infection

BACKGROUND

Kidney transplant recipients are a risk group for carbapenem-resistant Enterobacteriaceae infection.

OBJECTIVES

This study aimed to identify risk factors for CRE acquisition and infection among kidney transplant recipients.

METHODS

We conducted a case-control study; we defined the case as kidney transplant recipient with positive culture for carbapenem-resistant Enterobacteriaceae identified between January 2010 and February 2019. Controls were chosen among kidney transplant recipients hospitalized in the same period of cases (1:2). Surveillance culture for carbapenem-resistant Enterobacteriaceae was performed at admission and weekly during hospital stay. The risk factors analysis for carbapenem-resistant Enterobacteriaceae infection was performed among patients colonized by these bacteria.

RESULTS

We identified 331 patients colonized with carbapenem-resistant Enterobacteriaceae; The median time from transplantation to first carbapenem-resistant Enterobacteriaceae positive culture was 42 days (range from 3 to 7399 days); 125(37.8%) patients developed infection; the most common site was urinary tract. Risk factors for carbapenem-resistant Enterobacteriaceae acquisition were recipient age >45-year, diabetes nephropathy, donor age >55-year, ureteral stent at kidney transplantation, delay of graft function, median lymphocytes count <800cells/mm³, and acute cellular rejection. Risk factors for carbapenem-resistant Enterobacteriaceae infection were recipient age at CRE acquisition >50-year; median lymphocytes count ≤700 cells/mm³, carbapenem use, and colonization by polymyxin-resistant strain. Patients colonized by polymyxin and carbapenem resistant Enterobacteriaceae strain who used carbapenem had a 93.8% probability of developing infection by this agent.

CONCLUSION

Carbapenem-resistant Enterobacteriaceae acquisition after kidney transplant is related to graft conditions, immunosuppression degree. Among carbapenem-resistant Enterobacteriaceae colonized patients, special attention is needed for those harbouring polymyxin-resistant strains.

Efficacy and safety of tigecycline for complicated urinary tract infection: a systematic review

BACKGROUND

Facing the global threat of emerging resistance to antibiotics, tigecycline, a novel glycylcycline antibiotic, is developed to against multidrug-resistant pathogens, but not recommended for the treatment of complicated urinary tract infection (cUTI). We performed a summary of the literatures to characterize and evaluate the efficacy and safety of tigecycline in patients with cUTI.

METHODS

We searched PubMed, EMBASE, Cochrane and Clinical Trials using appropriate syntax to retrieve potential articles up to Jan 2020. General information, pathogen, medication regimen, comorbidities of patients from eligible literatures were recorded. Univariate logistic regression analysis was used to detect the potential factors associated with clinical cure.

RESULTS

Nineteen articles comprising 31 cases were included. The subpopulation with transplantation (25.8% of the patients) was the most common comorbidity, and cUTIs were mainly caused by Klebsiella pneumoniae (K. pneumoniae) (48.28%) in our research. Tigecycline 100 mg per day as monotherapy was most common. Clinical cure was reported as majority (77.4%), and microbiological eradication cases accounted for the most (65.2%) among the clinical cure cases. Univariate analysis showed that K. pneumoniae caused cUTI and tigecycline as a single treatment have significant meaning to clinical outcomes (P=0.044 and P=0.034, respectively).

CONCLUSIONS

Clinical and microbiological outcomes of tigecycline treatment revealed high rate of successful response. Tigecycline monotherapy may have a role in the treatment of cUTI except that caused by the pathogen K. pneumoniae. Further randomized controlled trials was still needed to evaluate tigecycline monotherapy for cUTI.

Multidrug-resistant Gram-negative bacterial infections in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of infections due to multidrug-resistant (MDR) Gram-negative bacilli in the pre- and post-transplant period. MDR Gram-negative bacilli, including carbapenem-resistant Enterobacteriaceae, MDR Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii, remain a threat to successful organ transplantation. Clinicians now have access to at least five novel agents with activity against some of these organisms, with others in the advanced stages of clinical development. No agent, however, provides universal and predictable activity against any of these pathogens, and very little is available to treat infections with MDR nonfermenting Gram-negative bacilli including A baumannii. Despite advances, empiric antibiotics should be tailored to local microbiology and targeted regimens should be tailored to susceptibilities. Source control remains an important part of the therapeutic armamentarium. Morbidity and mortality associated with infections due to MDR Gram-negative organisms remain unacceptably high. Heightened infection control and antimicrobial stewardship initiatives are needed to prevent these infections, curtail their transmission, and limit the evolution of MDR Gram-negative pathogens, especially in the setting of organ transplantation.

Infection related to Klebsiella pneumoniae producing carbapenemase in renal transplant patients

OBJECTIVE

To evaluate the risk factors related to Klebsiella pneumoniae carbapenemase infection after renal transplantation.

METHODS

This was a retrospective epidemiological (case-control) study, conducted from October 2011 to march 2016. Transplanted patients with infection by this bacteria during hospitalization were selected as cases. The controls were paired by age, sex, type of donor and transplant time. The proportion of cases and controls was 1:2.

RESULTS

Thirty hundred and five patients were included in the study (45 cases and 90 controls). The risk factors found for infection by KPC were: time of hospitalization after the transplant (OR: 4.82; CI95% 2.46-9.44), delayed kidney function (OR: 5.60; CI95% 1.91-11.01) and previous infectious for another microorganism ( OR: 34.13 CI95% 3.52-132.00).

CONCLUSION

The risk of acquisition of this bacterium was directly related to invasive procedures and exposure to the hospital environment. The findings reinforce the importance of prevention measures and control of infection by this microorganism.

Does the urinary tract infection caused by carbapenem-resistant Gram-negative bacilli impact the outcome of kidney transplant recipients?

The incidence of urinary tract infection (UTI) after kidney transplantation (KT) caused by multidrug-resistant (MDR) bacteria is growing. The aim of this study was to analyze the impact of UTI caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) in the survival of graft and recipients following KT. This was a retrospective cohort study involving patients who underwent KT between 2013 and 2016. Patients were followed since the day of the KT until loss of graft, death or end of the follow-up period (31th December 2016). The outcomes measured were UTI by MDR following KT and graft and patient survival. Analyses were performed using Cox regression; for the graft and patient survival analysis, we used a propensity score for UTI by CR-GNB to matching a control group. UTI was diagnosed in 178 (23.9%) of 781 patients, who developed 352 UTI episodes. 44.6% of the UTI cases were caused by MDR bacteria. Identified risk factors for UTI by MDR bacteria were DM, urologic disease as the cause of end-stage renal failure, insertion of ureteral stent, carbapenem use, and delayed graft function (DGF). Risk factors for death during the follow-up period were female gender, patients over 60 years old at the time of KT, DM, body mass index over 31.8, UTI caused by CR-GNB. In conclusion, UTIs caused by CR-GNB have great impact on patients' survival after KT.

The challenge of urinary tract infections in renal transplant recipients

Urinary tract infections (UTI) are an important cause of morbidity and mortality in renal transplant patients. These infections are quite common, and the goal of care is to identify and reduce risk factors while providing effective prophylaxis and treatment. Better understanding of long-term outcomes from these infections has led to the distinctions among UTI, recurrent UTI, and asymptomatic bacteriuria (ASB), and that each requires a different therapeutic approach. Specifically, new research has supported the perspective that asymptomatic bacteriuria should not be treated. Symptomatic UTI, on the other hand, requires intervention and remains an ongoing challenge for infectious disease clinicians. Many bacteria species are responsible for UTI in renal transplant patients, and in recent years there has been a global rise in infection caused by bacteria with newly acquired antibacterial resistance genes. Many renal transplant patients who experience UTI will also have multiple recurring episodes, which likely has a distinct pathophysiological mechanism leading to chronic colonization of the urinary tract. In these cases, long-term management includes bacterial suppression, which aims to reduce rather than eliminate bacteria to levels below the threshold for symptomatic infection. This review will address the current understanding of UTI epidemiology, pathogenesis, and risk factors in the renal transplant community, and also focus on current prevention and treatment strategies for patients who face an environment of increasingly antibiotic-resistant bacteria.

Impact of carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections in kidney transplantation

BACKGROUND

Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections in solid organ transplant patients are progressively increasing and are associated with worse outcomes, although potential risk factors and therapeutic strategies are still not well defined.

METHODS

We conducted a retrospective matched-pair analysis in which we compared 26 recipients CR-KP-positive after kidney transplantation (KT) with 52 CR-KP-negative patients transplanted in the same period, during a CR-KP outbreak that occurred in our hospital. Twenty-one patients (80%) received a combined antibiotic treatment. At the end of the follow-up, of the 26 CR-KP infected patients, 11 (42.3%) experienced at least one episode of re-infection, 9 (34.6%) remained colonized, and 6 (23.0%) had a symptomatic infection. Two of the 11 patients with re-infection died, while 9 were colonized at the end of the study.

RESULTS

A significantly better patient (P = .043) and graft (P < .001) survival was observed in CR-KP-negative patients. Univariate analysis identified the following variables as potential risk factors associated with CR-KP infection after KT: lower body mass index (P = .020); higher creatinine levels at post-transplant days 7 (P = .009), 15 (P = .026), and 30 (P = .019); longer hospital stay (P = .007); longer cold ischemia time (P = .004); delayed graft function (P = .020); and higher Clavien-Dindo score (P = .006).

CONCLUSION

The study confirmed that a CR-KP positivity may affect the outcome of a kidney transplant population. In severe CR-KP infections with sepsis, a combined antibiotic treatment seems to be advisable.

Management of multidrug resistant Gram-negative bacilli infections in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations

Solid organ transplant (SOT) recipients are especially at risk of developing infections by multidrug resistant (MDR) Gram-negative bacilli (GNB), as they are frequently exposed to antibiotics and the healthcare setting, and are regulary subject to invasive procedures. Nevertheless, no recommendations concerning prevention and treatment are available. A panel of experts revised the available evidence; this document summarizes their recommendations: (1) it is important to characterize the isolate's phenotypic and genotypic resistance profile; (2) overall, donor colonization should not constitute a contraindication to transplantation, although active infected kidney and lung grafts should be avoided; (3) recipient colonization is associated with an increased risk of infection, but is not a contraindication to transplantation; (4) different surgical prophylaxis regimens are not recommended for patients colonized with carbapenem-resistant GNB; (5) timely detection of carriers, contact isolation precautions, hand hygiene compliance and antibiotic control policies are important preventive measures; (6) there is not sufficient data to recommend intestinal decolonization; (7) colonized lung transplant recipients could benefit from prophylactic inhaled antibiotics, specially for Pseudomonas aeruginosa; (8) colonized SOT recipients should receive an empirical treatment which includes active antibiotics, and directed therapy should be adjusted according to susceptibility study results and the severity of the infection.

Carbapenem-resistant Enterobacteriaceae in special populations: Solid organ transplant recipients, stem cell transplant recipients, and patients with hematologic malignancies

Carbapenem-resistant Enterobacteriaceae (CRE) are a major global public health concern and pose a serious threat to immunocompromised hosts, particularly patients with hematologic malignancies and solid organ (SOT) and stem cell transplant recipients. In endemic areas, carbapenem-resistant Klebsiella pneumoniae infections occur in 1-18% of SOT recipients, and patients with hematologic malignancies represent 16-24% of all patients with CRE bacteremia. Mortality rates approaching 60% have been reported in these patient populations. Early diagnosis and rapid initiation of targeted therapy is critical in the management of immunocompromised hosts with CRE infections, as recommended empiric regimens are not active against CRE. Therapeutic options are limited by antibiotic-associated toxicities, interactions with immunosuppressive agents, and paucity of antibiotic options currently available. Prevention of CRE infection in these patients requires a multidisciplinary approach involving hospital epidemiology and antimicrobial stewardship. Large, multicenter studies are needed to develop risk-stratification tools to assist in guiding the management of these individuals.

Systematic review and meta-analysis of mortality of patients infected with carbapenem-resistant Klebsiella pneumoniae

PURPOSE

Carbapenem resistant K. pneumoniae (CRKP) has aroused widespread attention owing to its very limited therapeutic options, and this strain has increased rapidly in recent years. Although it is accepted that drug resistance is associated with increased mortality in general, but some other studies found no such relationship. To estimate mortality of patients infected with CRKP in general and analyze factors for mortality of this infection, thus, we conducted this systematic review and meta-analysis.

METHODS

A systematic literature review of relevant studies published until December 2015 was conducted. We selected and assessed articles reporting mortality of patients infected with CRKP.

RESULTS

Pooled mortality was 42.14% among 2462 patients infected with CRKP versus 21.16% in those infected with carbapenem-susceptible K. pneumoniae (CSKP). The mortality of patients with bloodstream infection (BSI) or urinary tract infection was 54.30 and 13.52%, respectively, and 48.9 and 43.13% in patients admitted to the intensive care unit (ICU) or who underwent solid organ transplantation (SOT). Mortality was 47.66% in patients infected with K. pneumoniae carbapenemase-producing K. pneumoniae and 46.71% in those infected with VIM-producing K. pneumoniae. Geographically, mortality reported in studies from North America, South America, Europe, and Asia was 33.24, 46.71, 50.06, and 44.82%, respectively.

CONCLUSIONS

Our study suggests that patients infected with CRKP have higher mortality than those infected with CSKP, especially in association with BSI, ICU admission, or SOT. We also considered that patients' survival has a close relationship with their physical condition. Our results imply that attention should be paid to CRKP infection, and that strict infection control measures and new antibiotics are required to protect against CRKP infection.

A prospective study of treatment of carbapenem-resistant Enterobacteriaceae infections and risk factors associated with outcome

BACKGROUND

To describe the clinical and microbiological data of carbapenem-resistant Enterobacteriaceae (CRE) infections, the treatment used, hospital- and infection-related mortality, and risk factors for death.

METHODS

A prospective cohort conducted from March 2011 to December 2012. Clinical, demographic, and microbiological data such as in vitro sensitivity, clonality, carbapenemase gene mortality related to infection, and overall mortality were evaluated. Data were analyzed using Epi Info version 7.0 (CDC, Atlanta, GA, USA) and SPSS (Chicago, IL, USA).

RESULTS

One hundred and twenty-seven patients were evaluated. Pneumonia, 52 (42 %), and urinary tract infections (UTI), 51 (40.2 %), were the most frequent sites of infection. The isolates were polyclonal; the Bla KPC gene was found in 75.6 % of isolates, and 27 % of isolates were resistant to colistin. Mortality related to infection was 34.6 %, and was higher among patients with pneumonia (61.4 %). Combination therapy was used in 98 (77.2 %), and monotherapy in 22.8 %; 96.5 % of them were UTI patients. Shock, age, and dialysis were independent risk factors for death. There was no difference in infection-related death comparing colistin-susceptible and colistin-resistant infections (p = 0.46); neither in survival rate comparing the use of combination therapy with two drugs or more than two drugs (p = 0.32).

CONCLUSIONS

CRE infection mortality was higher among patients with pneumonia. Infections caused by colistin-resistant isolates did not increase mortality. The use of more than two drugs on combination therapy did not show a protective effect on outcome. The isolates were polyclonal, and the bla KPC gene was the only carbapenemase found. Shock, dialysis, and age over 60 years were independent risk factors for death.

Outbreak of IMP-producing carbapenem-resistant Enterobacter gergoviae among kidney transplant recipients

OBJECTIVES

The objective of this study was to investigate a prolonged outbreak of carbapenem-resistant Enterobacter gergoviae (CREG) involving kidney transplant recipients (KTRs) between 2009 and 2014.

METHODS

A case-control study was undertaken. Controls (n = 52) were selected from CREG-negative KTRs. Surveillance cultures for CREG were collected weekly. Colonization was defined as isolation of CREG from surveillance samples or from clinical specimens, with no evidence of infection. We also investigated infection control practices at the facility.

RESULTS

Of 26 identified cases, 13 had had no known contact with another CREG-positive patient before the first positive culture. Seven patients (27%) developed infection. The site most often colonized was the urinary tract. During the study period two clusters were identified, one in 2009 and another in 2013-14. DNA sequencing revealed blaIMP-1 in all CREG tested. No environmental or hand cultures tested positive for CREG. An audit of infection control practices detected flaws in the handling and cleaning of urinary tract devices. Multivariate analysis identified advanced age, ureteral stent use, retransplantation and male gender as risk factors for CREG acquisition.

CONCLUSIONS

An outbreak among KTRs caused by an unusual species of MDR bacteria may have resulted from a common source of contamination related to urinary tract devices.

Epidemiology and outcomes of carbapenem-resistant Klebsiella pneumoniae bacteriuria in kidney transplant recipients

BACKGROUND

Little is known about the epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria following kidney transplantation. We determined the incidence of post-transplant CRKP bacteriuria in adults who underwent kidney transplant from 2007 to 2010 at 2 New York City centers.

METHODS

We conducted a case-control study to identify factors associated with CRKP bacteriuria compared with carbapenem-susceptible K. pneumoniae (CSKP) bacteriuria, assessed whether CRKP bacteriuria was associated with mortality or graft failure, and compared outcomes of treated episodes of CRKP and CSKP bacteriuria.

RESULTS

Of 1852 transplants, 20 (1.1%) patients developed CRKP bacteriuria. Factors associated with CRKP bacteriuria included receipt of multiple organs (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.1-20.4), deceased-donor allograft (OR 5.9, 95% CI 1.3-26.8), transplant admission length of stay (OR 1.1 per day, 95% CI 1.0-1.1), pre-transplant CRKP infection or colonization (OR 18.3, 95% CI 2.0-170.5), diabetes mellitus (OR 2.8, 95% CI 1.0-7.8), and receipt of antimicrobials other than trimethoprim-sulfamethoxazole (OR 4.3, 95% CI 1.6-11.2).

CONCLUSION

Compared to CSKP bacteriuria, CRKP bacteriuria was associated with increased mortality (30% vs. 10%, P = 0.03) but not graft failure. Treated episodes of CRKP bacteriuria were less likely to achieve microbiologic clearance (83% vs. 97%; P = 0.05) and more likely to recur within 3 months (50% vs. 22%, P = 0.02) than CSKP episodes. CRKP bacteriuria after kidney transplant is associated with mortality and antimicrobial failure after treatment.

Management of urinary tract infection in solid organ transplant recipients: Consensus statement of the Group for the Study of Infection in Transplant Recipients (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Network for Research in Infectious Diseases (REIPI)

BACKGROUND

Urinary tract infections (UTIs) are one of the most common infections in solid organ transplant (SOT) recipients.

METHODS

Experienced SOT researchers and clinicians have developed and implemented this consensus document in support of the optimal management of these patients. A systematic review was conducted, and evidence levels based on the available literature are given for each recommendation. This article was written in accordance with international recommendations on consensus statements and the recommendations of the Appraisal of Guidelines for Research and Evaluation II (AGREE II).

RESULTS

Recommendations are provided on the management of asymptomatic bacteriuria, and prophylaxis and treatment of UTI in SOT recipients. The diagnostic-therapeutic management of recurrent UTI and the role of infection in kidney graft rejection or dysfunction are reviewed. Finally, recommendations on antimicrobials and immunosuppressant interactions are also included.

CONCLUSIONS

The latest scientific information on UTI in SOT is incorporated in this consensus document.

Risk factors and outcome of infections with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae in kidney transplant recipients

INTRODUCTION

Solid organ transplant recipients are especially susceptible to healthcare-associated infections with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp-HAIs). The aim of the study was to evaluate risk factors and outcome of these infections in kidney transplant recipients.

METHODS

This was a retrospective cohort of kidney transplant (KTx) recipients between January 2009 and December 2013. Cases were defined as patients who developed KPC-Kp-HAI, confirmed by PCR for bla( KPC) gene after KTx during the study period. We analysed variables related to recipient; induction immunosuppressant therapy; delayed graft function; use of invasive devices; SOFA score on the first day of infection; type of therapy; time from positive culture to appropriate antimicrobial therapy; bacteraemia; and concomitant infection. Outcome measures were the occurrence of KPC-Kp-HAI and 30-day mortality after KPC-Kp-HAI.

RESULTS

A total of 1,101 were submitted to KTx in the period, 21 patients were classified as infected with KPC-Kp. Another ten patients had KPC-Kp-HAI in the period and were transplanted before 2009. Of those 31 patients, 48.4 % showed evidence of prior colonization and 38.7 % had bacteraemia. The most common site of infection was the surgical wound. Risk factors for KPC-Kp-HAI were multi-organ transplantation and the use of a ureteral stent. Eight of the infected patients experienced recurrence of the infection. The 30-day mortality rate was 41.9 %. Survival was significantly lower among the patients with KPC-Kp-HAI (72 vs. 89.1 %; P = 0.002). The only risk factor independently associated with 30-day mortality was an elevated SOFA score on the first day of infection.

CONCLUSIONS

In KTx recipients, the occurrence of KPC-Kp-HAI was related to invasive devices and type of transplant; these infections had a high rate of recurrence and reduced survival after KTx.

Carbapenem-resistant Klebsiella pneumoniae urinary tract infection following solid organ transplantation

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging pathogen with a devastating impact on organ transplant recipients (OTRs). Data describing urinary tract infections (UTIs) due to CRKP, compared to extended-spectrum β-lactamase (ESBL)-producing and susceptible K. pneumoniae, are lacking. We conducted a retrospective cohort study comparing OTRs with a first episode of UTI due to CRKP, ESBL-producing K. pneumoniae, or susceptible K. pneumoniae. We identified 108 individuals; 22 (20%) had UTIs due to CRKP, 22 (20%) due to ESBL-producing K. pneumoniae, and 64 (60%) due to susceptible K. pneumoniae. Compared to susceptible K. pneumoniae (27%), patients with UTIs due to CRKP or ESBL-producing K. pneumoniae were more likely to have a ≥ 24-hour stay in the intensive care unit (ICU) before or after development of the UTI (64% and 77%, respectively; P < 0.001). Among 105/108 hospitalized patients (97%), the median lengths of stay prior to UTI with CRKP or ESBL-producing K. pneumoniae (7 and 8 days, respectively) were significantly longer than that for susceptible K. pneumoniae (1 day; P < 0.001). Clinical failure was observed for 8 patients (36%) with CRKP, 4 (18%) with ESBL-producing K. pneumoniae, and 9 (14%) with susceptible K. pneumoniae (P = 0.073). Microbiological failure was seen for 10 patients (45%) with CRKP, compared with 2 (9%) with ESBL-producing K. pneumoniae and 2 (3%) with susceptible K. pneumoniae (P < 0.001). In multivariable logistic regression analyses, CRKP was associated with greater odds of microbiological failure (versus ESBL-producing K. pneumoniae: odds ratio [OR], 9.36, 95% confidence interval [CI], 1.94 to 72.1; versus susceptible K. pneumoniae: OR, 31.4, 95% CI, 5.91 to 264). In conclusion, CRKP is associated with ICU admission, long length of stay, and microbiological failure among OTRs with UTIs. Greater numbers are needed to determine risk factors for infection and differences in meaningful endpoints associated with carbapenem resistance.

The global challenge of carbapenem-resistant Enterobacteriaceae in transplant recipients and patients with hematologic malignancies

Carbapenem-resistant Enterobacteriaceae (CRE) are emerging global pathogens. The spread of CRE to transplant recipients and patients with hematologic malignancies has ominous implications. These patients rely on timely, active antibacterial therapy to combat gram-negative infections; however, recommended empirical regimens are not active against CRE. Approximately 3%-10% of solid organ transplant (SOT) recipients in CRE-endemic areas develop CRE infection, and the infection site correlates with the transplanted organ. Mortality rates associated with CRE infections approach 40% in SOT recipients and 65% in patients with hematologic malignancies. Given that the current antimicrobial armamentarium to combat CRE is extremely limited, a multifaceted approach that includes antimicrobial stewardship and active surveillance is needed to prevent CRE infections in immunocompromised hosts. Improving outcomes of established infections will require the use of risk factor-based prediction tools and molecular assays to more rapidly administer CRE-active therapy and the development of new antimicrobial agents with activity against CRE.