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Carbapenem Resistance, Initial Antibiotic Therapy, and Mortality in Klebsiella pneumoniae Bacteremia: A Systematic Review and Meta-Analysis

Published online by Cambridge University Press:  27 September 2017

Philipp P. Kohler ,
Cheryl Volling ,
Karen Green ,
Elizabeth M. Uleryk ,
Prakesh S. Shah  and
Allison McGeer
Philipp P. Kohler*
Affiliation:
Mount Sinai Hospital, Toronto, Ontario, Canada University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada Clinic for Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
Cheryl Volling
Affiliation:
Mount Sinai Hospital, Toronto, Ontario, Canada
Karen Green
Affiliation:
Mount Sinai Hospital, Toronto, Ontario, Canada
Elizabeth M. Uleryk
Affiliation:
Mount Sinai Hospital, Toronto, Ontario, Canada E.M. Uleryk Consulting, Mississauga, Ontario, Canada
Prakesh S. Shah
Affiliation:
Mount Sinai Hospital, Toronto, Ontario, Canada University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
Allison McGeer
Affiliation:
Mount Sinai Hospital, Toronto, Ontario, Canada University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
*
Address correspondence to Philipp Kohler, MD, MSc, Clinic for Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007 St. Gallen, Switzerland (philipp.kohler@kssg.ch).
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Abstract

BACKGROUND

Mortality associated with infections caused by carbapenem-resistant Enterobacteriaceae (CRE) is higher than mortality due to carbapenem-sensitive pathogens.

OBJECTIVE

To examine the association between mortality from bacteremia caused by carbapenem-resistant (CRKP) and carbapenem-sensitive Klebsiella pneumoniae (CSKP) and to assess the impact of appropriate initial antibiotic therapy (IAT) on mortality.

DESIGN

Systematic review and meta-analysis

METHODS

We searched MEDLINE, EMBASE, CINAHL, and Wiley Cochrane databases through August 31, 2016, for observational studies reporting mortality among adult patients with CRKP and CSKP bacteremia. Search terms were related to Klebsiella, carbapenem-resistance, and infection. Studies including fewer than 10 patients per group were excluded. A random-effects model and meta-regression were used to assess the relationship between carbapenem-resistance, appropriateness of IAT, and mortality.

RESULTS

Mortality was higher in patients who had CRKP bacteremia than in patients with CSKP bacteremia (15 studies; 1,019 CRKP and 1,148 CSKP patients; unadjusted odds ratio [OR], 2.2; 95% confidence interval [CI], 1.8–2.6; I2=0). Mortality was lower in patients with appropriate IAT than in those without appropriate IAT (7 studies; 658 patients; unadjusted OR, 0.5; 95% CI, 0.3–0.8; I2=36%). CRKP patients (11 studies; 1,326 patients; 8-year period) were consistently less likely to receive appropriate IAT (unadjusted OR, 0.5; 95% CI, 0.3–0.7; I2=43%). Our meta-regression analysis identified a significant association between the difference in appropriate IAT and mortality (OR per 10% difference in IAT, 1.3; 95% CI, 1.0–1.6).

CONCLUSIONS

Appropriateness of IAT is an important contributor to the observed difference in mortality between patients with CRKP bacteremia and patients with CSKP bacteremia.

Infect Control Hosp Epidemiol 2017;38:1319–1328

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 11 , November 2017 , pp. 1319 - 1328
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

PREVIOUS PRESENTATION. An oral presentation of this work was given at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) on April 23, 2017, in Vienna, Austria.

a

Authors with equal contribution.

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