A Multinational Survey of Risk Factors for Infection with Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Nonhospitalized Patients

• Published in: Clinical infectious diseases 2009-09, Vol.49 (5), p.682-690
• Main Authors: Ben-Ami, Ronen, Rodríguez-Baño, Jesús, Arslan, Hande, Pitout, Johann D. D., Quentin, Claudine, Calbo, Esther S., Azap, Özlem K., Arpin, Corinne, Pascual, Alvaro, Livermore, David M., Garau, Javier, Carmeli, Yehuda
• Format: Article
• Language: English
• Subjects: Antibiotics; Articles and Commentaries; Bacteria; beta-Lactam Resistance; beta-Lactamases; beta-Lactamases - biosynthesis; beta-Lactamases - genetics; Biological and medical sciences; Community-Acquired Infections; Community-Acquired Infections - epidemiology; Community-Acquired Infections - microbiology; Enterobacteriaceae; Enterobacteriaceae - drug effects; Enterobacteriaceae - enzymology; Enterobacteriaceae Infections; Enterobacteriaceae Infections - epidemiology; Enterobacteriaceae Infections - microbiology; Enzymes; Escherichia coli; Female; Global Health; Health Surveys; Humans; Infections; Infectious diseases; Life Sciences; Male; Medical sciences; Microbial Sensitivity Tests; Microbiology and Parasitology; Modeling; Multivariate Analysis; Operating rooms; Predisposing factors; Prevalence; Risk Factors; ROC Curve; World Health
• ISSN: 1058-4838; 1537-6591
• DOI: 10.1086/604713

Background. Infections caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae are increasing in frequency and are associated with high mortality rates. Circulation of CTX-M-type ESBLs in the community is of particular concern, because it may confound standard infection-control measures. Methods. We analyzed the results of epidemiologic studies of infection caused by ESBL-producing Enterobacteriaceae in nonhospitalized patients from 6 centers in Europe, Asia, and North America. Risk factors for infection with an ESBL-producing organism were identified by univariate and multivariate analyses. Results. A total of 983 patient-specific isolates were reviewed (890 [90.5%] of which were Escherichia coli, 68 [6.9%] of which were Klebsiella species, and 25 [2.5%] of which were Proteus mirabilis ); 339 [34.5%] of the isolates produced ESBLs. CTX-M types were the most frequent ESBLs (accounting for 65%). Rates of co-resistance to ciprofloxacin among ESBL-producing isolates were high (>70%), but significant variation was seen among centers with respect to rates of resistance to gentamicin, amoxicillin-clavulanate, and trimethoprim-sulfamethoxazole. Similar risk factors for infection with an ESBL-producing organism were found in the different participating centers. Significant risk factors, identified by multivariate analysis, were recent antibiotic use, residence in a long-term care facility, recent hospitalization, age ⩾65 years, and male sex (area under the receiver-operator characteristic [ROC] curve, 0.80). However, 34% of ESBL-producing isolates (115 of 336 isolates) were obtained from patients with no recent health care contact; the area under the ROC curve for the multivariate model for this group of patients was only 0.70, which indicated poorer predictive value. Conclusions. Community-acquired ESBL-producing Enterobacteriaceae are now prevalent worldwide, necessitating international collaboration. Novel approaches are required to adequately address issues such as empirical treatment for severe community-acquired infection and infection control.