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Unique Risks and Clinical Outcomes Associated With Extended-Spectrum β-Lactamase Enterobacteriaceae in Veterans With Spinal Cord Injury or Disorder: A Case-Case-Control Study

Published online by Cambridge University Press:  30 March 2016

Margaret A. Fitzpatrick ,
Katie J. Suda ,
Nasia Safdar ,
Barry Goldstein ,
Makoto M. Jones ,
Linda Poggensee ,
Swetha Ramanathan ,
Ryan LeWan  and
Charlesnika T. Evans
Margaret A. Fitzpatrick*
Affiliation:
Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA Hospital, Hines, Illinois Department of Medicine, Division of Infectious Diseases, Loyola University Stritch School of Medicine, Maywood, Illinois
Katie J. Suda
Affiliation:
Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA Hospital, Hines, Illinois Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
Nasia Safdar
Affiliation:
Department of Veterans’ Affairs, William S. Middleton VA Medical Center, Madison, Wisconsin Department of Medicine, Division of Infectious Diseases, University of Wisconsin, Madison, Wisconsin
Barry Goldstein
Affiliation:
Department of Veterans’ Affairs, Office of Spinal Cord Injury and Disorders Services, VA Puget Sound Healthcare System, Seattle, Washington Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
Makoto M. Jones
Affiliation:
Department of Veterans’ Affairs, VA Salt Lake City Healthcare System, Salt Lake City, Utah Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, Utah
Linda Poggensee
Affiliation:
Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA Hospital, Hines, Illinois
Swetha Ramanathan
Affiliation:
Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA Hospital, Hines, Illinois Department of Veterans’ Affairs, Department of Pharmacy, Edward Hines, Jr., VA Hospital, Hines, Illinois
Ryan LeWan
Affiliation:
Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA Hospital, Hines, Illinois
Charlesnika T. Evans
Affiliation:
Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare and Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines, Jr. VA Hospital, Hines, Illinois Center for Healthcare Studies and Department of Preventive Medicine Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
*
Address correspondence to Margaret A. Fitzpatrick, MD, MS, 5000 S. 5th Ave., Hines, IL 60141 (Margaret.fitzpatrick@va.gov).
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Abstract

OBJECTIVES

To describe the burden of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae in veterans with spinal cord injury or disorder (SCI/D), to identify risk factors for ESBL acquisition, and to assess impact on clinical outcomes

DESIGN

Retrospective case-case-control study

PATIENTS AND SETTING

Veterans with SCI/D and utilization at a Veterans’ Affairs medical center from January 1, 2012, to December 31, 2013.

METHODS

Patients with a positive culture for ESBL Klebsiella pneumoniae, Escherichia coli, or Proteus mirabilis were matched with patients with non-ESBL organisms by organism, facility, and level of care and to uninfected controls by facility and level of care. Inpatients were also matched by time at risk. Univariate and multivariate matched models were assessed for differences in risk factors and outcomes.

RESULTS

A total of 492 cases (62.6% outpatients) were matched 1:1 with each comparison group. Recent prior use of fluoroquinolones and prior use of third- and fourth-generation cephalosporins were independently associated with ESBL compared to the non-ESBL group (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.77–3.84; P<.001 for fluoroquinolones and aOR, 3.86; 95% CI, 2.06–7.25; P<.001 for third- and fourth-generation cephalosporins) and the control group (aOR, 2.10; 95% CI, 1.29–3.43; P = .003 for fluoroquinolones; and aOR, 3.31; 95% CI, 1.56–7.06; P=.002 for third- and fourth-generation cephalosporins). Although there were no differences in mortality rate, the ESBL group had a longer post-culture length of stay (LOS) than the non-ESBL group (incidence rate ratio, 1.36; 95% CI, 1.13–1.63; P=.001).

CONCLUSIONS

All SCI/D patients with ESBL were more likely to have had recent exposure to fluoroquinolones or third- and fourth-generation cephalosporins, and hospitalized patients were more likely to have increased post-culture LOS. Programs targeted toward reduced antibiotic use in SCI/D patients may prevent subsequent ESBL acquisition.

Infect Control Hosp Epidemiol 2016;37:768–776

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 37 , Issue 7 , July 2016 , pp. 768 - 776
Copyright
© 2016 by The Society for Healthcare Epidemiology of America. All rights reserved 

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