Carbapenem use in extended-spectrum cephalosporin-resistant Enterobacterales infections in US hospitals and influence of IDSA guidance: a retrospective cohort study

Authors

Morgan K. Walker, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Guoqing Diao, Department of Biostatistics, George Washington University, Washington, DC, USA.
Sarah Warner, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Ahmed Babiker, Emory University School of Medicine, Atlanta, GA, USA.
Maniraj Neupane, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Jeffrey R. Strich, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Christina Yek, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Sameer S. Kadri, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA. Electronic address: sameer.kadri@nih.gov.

Document Type

Journal Article

Publication Date

4-25-2024

Journal

The Lancet. Infectious diseases

DOI

10.1016/S1473-3099(24)00149-X

Abstract

BACKGROUND: Disparate and rapidly changing practice recommendations from major professional infectious diseases societies for managing non-severe infections caused by extended-spectrum β-lactamase-producing Enterobacterales might hamper carbapenem stewardship. We aimed to understand the real-world management of extended-spectrum cephalosporin-resistant (ECR) Enterobacterales infections in US hospitals and factors influencing preference for carbapenems over alternative treatments. METHODS: This retrospective cohort study included adults (aged ≥18 years) admitted to hospital with ECR Enterobacterales infections in the PINC AI database. Antibiotic regimens were assessed during empirical and targeted treatment periods and by infection severity and site. Likelihood of receiving targeted carbapenems over time and before or after initial release of the Infectious Diseases Society of America (IDSA) guidance on Sept 8, 2020, was established with generalised estimating equations controlling for patient, hospital, and temporal confounders. FINDINGS: Between Jan 1, 2018, and Dec 31, 2021, 30 041 inpatient encounters with ECR Enterobacterales infections were identified at 168 US hospitals, of which 16 006 (53·3%) encounters were in women and 14 035 (46·7%) were in men, with a mean age of 67·3 years (SD 15·1). Although few patients received carbapenems empirically (5324 [17·7%] of 30 041), many did so as targeted treatment (17 518 [58·3%] of 30 041), including subgroups of patients without septic shock (3031 [45·6%] of 6651) and patients with urinary tract infections without septic shock (1845 [46·8%] of 3943) in whom specific narrower-spectrum alternatives were active. Transitions from non-carbapenem to carbapenem antibiotics occurred most often on the day that the ECR phenotype was reported, regardless of illness severity. Carbapenems were the predominant choice to treat ECR Enterobacterales infections over time (adjusted odds ratio 1·00 [95% CI 1·00-1·00]), with no additional immediate change (1·07 [0·95-1·20]) or sustained change (0·99 [0·98-1·00]) after IDSA guidance release. INTERPRETATION: High carbapenem use in targeting non-severe ECR Enterobacterales infections in US hospitals predates 2020 IDSA guidance and has persisted thereafter. Efforts to increase awareness and implementation of recommendations among clinicians to use carbapenem-sparing alternatives in ECR Enterobacterales infections might decrease global carbapenem selective pressure. FUNDING: US National Institutes of Health Intramural Research Program, National Institute of Allergy and Infectious Diseases, and US Food and Drug Administration.

APA Citation

Walker, Morgan K.; Diao, Guoqing; Warner, Sarah; Babiker, Ahmed; Neupane, Maniraj; Strich, Jeffrey R.; Yek, Christina; and Kadri, Sameer S., "Carbapenem use in extended-spectrum cephalosporin-resistant Enterobacterales infections in US hospitals and influence of IDSA guidance: a retrospective cohort study" (2024). GW Authored Works. Paper 4672.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/4672

Department

Biostatistics and Bioinformatics