Invasive Klebsiella pneumoniae Infections in Community-Settings and Healthcare Settings

Figures & data

Table 1 Characteristics of the Children with Invasive Klebsiella pneumoniae Infection According to Type of Acquired Infections (HAI or CAI)

Variable	Total (n=324)	HAI (N=275)	CAI (N=49)	P value
Age (months)	0.8 (0.3–6.4)	0.6 (0.17–6)	3.0 (0.87–10)	0.54
Male	187 (57.7)	154 (56)	33 (67.3)	0.14
Rural area	178 (54.9)	156 (56.7)	22 (44.9)	0.13
Underlying disease
Hematologic malignancies	45 (13.9)	44 (16)	1 (2)	0.02
Congenital anomalies	42 (13)	37 (13.5)	5 (10.2)	0.53
NEC	27 (8.3)	27 (9.8)	0 (0)	0.02
Prematurity	131 (40.4)	129 (46.9)	2 (4.1)	0
Solid tumors	4 (1.2)	4 (1.5)	0 (0)	1
Severe Malnutrition	12 (3.7)	11 (4)	1 (2)	0.8
Immunodeficiencies	3 (0.9)	3 (1.1)	0 (0)	1
Departments
● Hematology-oncology ward	42 (13)	42 (15.3)	0 (0)	<0.01
● General medical ward	157 (48.5)	119 (43.3)	38 (77.6)	0
● NICU	65 (20.1)	64 (23.3)	1 (2)	0
● PICU	21 (6.5)	18 (6.5)	3 (6.1)	1
● Surgical ward	39 (12)	32 (11.6)	7 (14.3)	0.6
Length of hospitalization	28 (17–50)	33 (21–53.5)	13 (9–16)	0
Length of hospitalization before the onset of KP infections	7 (1.8–20)	10 (2–22)	1 (1–1)	0
Invasive procedures and devices
PICC	83 (25.6)	82 (29.8)	1 (2)	0
Thoracic cavity drainage	12 (3.7)	12 (4.4)	0 (0)	0.23
Abdominal indwelling catheter	4 (1.2)	4 (1.5)	0 (0)	1
Indwelling urinary catheter	8 (2.5)	5 (1.8)	3 (6.1)	0.2
Invasive mechanical ventilation	97 (29.9)	96 (34.9)	1 (2)	0
Surgical operation	65 (20.1)	60 (21.8)	5 (10.2)	0.06
Organ dysfunction (any)	73 (22.5)	69 (25.1)	4 (8.2)	0.015
Septic shock	32 (9.9)	30 (10.9)	2 (4.1)	0.22
Mortality or hopeless discharge	44 (13.6)	39 (14.2)	5 (8.2)	0.45
Isolation of CRKP (N=304)	116 (38.2)	112 (43.4)	4 (8.7)	0
Combined organ infection
Pneumonia	139 (42.9)	119 (43.3)	20 (40.8)	0.75
Meningitis	67 (20.1)	64 (23.3)	3 (6.1)	0
Intrabdominal infections	46 (14.2)	41 (14.9)	5 (10.2)	0.38
Upper urinary tract infections	18 (5.6)	3 (1.1)	15 (30.6)	0

Abbreviations: HAI, healthcare-associated infections; CAI, community-acquired infections; PICC, peripherally inserted central catheter; NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit; CRKP, carbapenem‐resistant Klebsiella pneumoniae.

Table 2 Multiple Regression Analysis of Risk Factors Associated with HAI

Variable	Total	HAI	CAI	Multi-Variate Analysis
				P value	OR	95% CI
Underlying disease
Hematologic malignancies	45 (13.9)	44 (16)	1 (2)	0.01	15.52	1.89–127.14
Prematurity	131 (40.4)	129 (46.9)	2 (4.1)	<0.01	37.07	8.29–165.84
Departments
General medical ward	157 (48.5)	119 (43.3)	38 (77.6)	<0.01	0.2	0.08–0.51
NICU	65 (20.1)	64 (23.3)	1 (2)	0.11	5.82	0.68–49.89
Previous use invasive mechanical ventilation	82 (25.3)	81 (29.5)	1 (2)	0.01	13.09	1.66–103.56
Antibiotic therapy prior to admission	90 (27.8)	80 (29.1)	10 (20.4)	0.14	2.02	0.79–5.19

Abbreviations: NICU, neonatal intensive care unit; HAI, healthcare-associated infections; CAI, community-acquired infections.

Table 3 Characteristics of the Children with HAI According to Pattern of Carbapenem Resistance (CRKP or CSKP Isolates)

Variable	CRKP (N=112)	CSKP (N=146)	P value
Age (months)	0.53 (0.12–3.2)	0.65 (0.17–12)	0.27
Male	62 (55.4)	82 (56.2)	0.9
Rural area	74 (66.1)	72 (49.3)	<0.01
Underlying disease
Hematologic malignancies	18 (16.1)	26 (17.8)	0.71
Congenital anomalies	19 (17)	16 (11)	0.16
Prematurity	58 (51.8)	61 (41.8)	0.11
NEC	9 (8)	15 (10.3)	0.54
Solid tumors	2 (1.8)	1 (0.7)	0.58
Severe malnutrition	7 (6.3)	4 (2.7)	0.28
Departments
● Hematology-oncology ward	17 (15.2)	25 (17.1)	0.68
● General medical ward	56 (50)	58 (39.7)	0.1
● NICU	13 (11.6)	44 (30.1)	<0.01
● PICU	8 (7.1)	7 (4.8)	0.42
● Surgical ward	18 (16.1)	12 (8.2)	0.051
Length of hospitalization	38.5 (24–56.3)	30 (19.3–51.8)	0
Length of hospitalization before the onset of KP infections	12.5 (2–24.3)	10 (2–22)	0.02
Invasive procedures and devices
PICC	37 (33)	43 (29.5)	0.54
Thoracic cavity drainage	6 (5.4)	6 (4.1)	0.64
Abdominal indwelling catheter	3 (2.7)	1 (0.7)	0.32
Indwelling urinary catheter	1 (0.9)	4 (2.7)	0.39
Invasive mechanical ventilation	51 (45.5)	39 (26.7)	<0.01
Surgical operation	23 (20.5)	32 (21.9)	0.79
Organ dysfunction (any)	41 (36.6)	22 (15.1)	<0.01
Septic shock	13 (11.6)	13 (8.9)	0.48
Mortality or hopeless discharge	16 (14.3)	19 (13)	0.77
Combined organ infection
Pneumonia	54 (48.2)	60 (41.1)	0.25
Meningitis	34 (30.4)	21 (14.4)	<0.01
Intrabdominal infections	15 (13.4)	23 (15.8)	0.6
Upper urinary tract infections	2 (1.8)	1 (0.7)	0.58

Abbreviations: CRKP, carbapenem‐resistant Klebsiella pneumoniae; CSKP, carbapenem-sensitive Klebsiella pneumoniae; KP, Klebsiella pneumoniae; PICC, peripherally inserted central catheter; NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit.

Table 4 Multiple Regression Analysis of Risk Factors Associated with CRKP Infections in HAI

Variable	Total (N=258)	CRKP (N=112)	CSKP (N=146)	Multi-Variate Analysis
				P value	OR (95% CI)
Rural area	146 (56.6)	74 (66.1)	72 (49.3)	0.02	1.94 (1.12–3.35)
Congenital anomalies	35	19 (17)	16 (11)	0.18	1.77 (0.78–4.01)
Prematurity	119	58 (51.8)	61 (41.8)	0.07	1.95 (0.95–4.01)
Surgical prior to admission	18 (7)	8 (7.1)	10 (6.8)	0.8	0.87 (0.29–2.57)
Antibiotic therapy prior to admission	70 (27.1)	42 (37.5)	28 (19.2)	<0.01	2.33 (1.25–4.33)
Previous use PICC	73 (28.3)	34 (30.4)	39 (26.7)	0.98	0.99 (0.46–2.15)
Previous use invasive mechanical ventilation	76 (29.5)	43 (38.4)	33 (22.6)	0.02	2.08 (1.12–3.88)
Hospital stay prior to admission in 30days	101 (39.1)	57 (50.9)	44 (30.1)	<0.01	3.46 (1.87–6.41)

Abbreviation: PICC, peripherally inserted central catheter.

Table 5 Multiple Regression Analysis of Risk Factors Associated with Poor Outcomes in HAI

Variable	Survived N=236	Poor Outcome N=39	Univariate Analysis		Multi-Variate Analysis
			P value	OR (95% CI)	P value	OR (95% CI)
Age (months)	0.6 (0.1–4.8)	1.0 (0.4–6.7)	0.75	1.0 (0.99–1.0)
Male	132 (55.9)	22 (56.4)	0.96	1.02 (0.52–2.02)
Rural area	132 (55.9)	24 (61.5)	0.51	1.26 (0.63–2.52)
Underlying disease
Hematologic malignancies	39 (16.5)	5 (12.8)	0.56	0.74 (0.27–2.02)
Congenital anomalies	31 (13.1)	6 (15.4)	0.7	1.2 (0.47–3.1)
NEC	22 (9.3)	5 (12.8)	0.5	1.43 (0.51–4.03)
Prematurity	3 (1.3)	1 (2.6)	0.92	0.97 (0.49–1.9)
Solid tumors	3 (1.3)	1 (2.6)	0.54	2.04 (0.21–20.16)
Severe malnutrition	9 (3.8)	2 (5.1)	0.7	1.36 (0.28–6.56)
Immunodeficiencies	2 (0.8)	1 (2.6)	0.36	3.08 (0.27–34.79)
Length of hospitalization before the onset of BSI	10 (2–12)	10 (2–11)	0.44	0.99 (0.97–1.01)
Invasive procedures and devices
PICC	69 (29.2)	13 (33.3)	0.61	1.21 (0.59–2.49)
Thoracic cavity drainage	11 (4.7)	1 (2.6)	0.56	0.54 (0.07–4.29)
Abdominal indwelling catheter	3 (1.3)	1 (2.6)	0.54	2.04 (0.21–20.16)
Indwelling urinary catheter	4 (1.7)	1 (2.6)	0.71	1.53 (0.17–14.03)
Invasive mechanical ventilation	77 (32.6)	19 (48.7)	0.05	1.96 (0.99–3.89)	0.88	0.93 (0.39–2.21)
Operation	51 (21.6)	9 (23.1)	0.84	1.09 (0.49–2.44)
Organ dysfunction (any)	50 (21.2)	19 (48.7)	0	3.53 (1.75–7.13)	0.02	2.92 (1.23–6.95)
Septic shock	21 (8.9)	9 (23.1)	0.01	3.07 (1.29–7.33)	0.08	2.29 (0.9–5.85)
Isolation of CRKP (N=304)	96 (35.7)	16 (45.7)	0.25
Combined organ infection
Pneumonia	98 (41.5)	21 (53.8)	0.15	1.64 (0.83–3.25)	0.58	1.22 (0.59–2.53)
Meningitis	53 (22.5)	11 (28.2)	0.43	1.36 (0.63–2.91)	0.31	0.52 (0.15–1.85)
Intrabdominal infections	38 (16.1)	3 (7.7)	0.18	0.43 (0.13–1.48)
Upper urinary tract infections	3 (1.3)	0 (0)	-	-

Abbreviations: HAI, healthcare-associated infections; PICC, peripherally inserted central catheter; NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit; CRKP, carbapenem‐resistant Klebsiella pneumoniae.

Table 6 Resistance Patterns of Klebsiella pneumoniae

Antimicrobial Drugs	Percentage Rate (%) of Resistance^a (Number of Isolates Resistant/Number of Isolates Tested)
	Total	HAI	CAI	P value
Ampicillin	93.8 (227/242)	96.6 (199/206)	77.8 (28/36)	0
Ampicillin/Sulbactam	75.6 (205/271)	81.5 (190/233)	39.5 (15/38)	0
Cefepime	55.3 (167/302)	60.5 (155/256)	26.1 (12/46)	0
Ceftriaxone	59.8 (76/127)	70.2 (73/104)	13 (3/23)	0
Ceftazidime	62.7 (188/300)	69.4 (177/255)	24.4 (11/45)	0
Cefuroxime	58.6 (17/29)	66.7 (16/24)	20 (1/5)	0.13
Piperacillin/tazobactam	43 (128/298)	48.6 (124/255)	9.3 (4/43)	0
Gentamicin	30.6 (92/301)	34.5 (88/255)	8.7 (4/46)	0
Amikacin	14.2 (43/302)	16.4 (42/256)	2.2 (1/46)	0.02
Ciprofloxacin	20.8 (63/303)	23.7 (61/257)	4.3 (2/46)	<0.01
Levofloxacin	18.2 (55/303)	21 (54/257)	2.2 (1/46)	<0.01
Imipenem	36.2 (110/304)	41.5 (107/258)	6.5 (3/46)	0
Meropenem	40.5 (96/237)	45.4 (93/205)	9.4 (3/32)	0
Tigecycline	10.5 (2/19)	12.5 (2/16)	0 (0/3)	1
Polymycin B	0.6 (1/169)	0.7 (1/148)	0 (0/21)	1

Note: ^aKlebsiella pneumoniae isolates displaying intermediate susceptibility were not categorized as resistance in this study.

Abbreviations: HAI, healthcare-associated infections; CAI, community-acquired infections.