Epidemiology of Carbapenem-Resistant Enterobacterales Infection and Colonization in Hospitalized Patients at a University Hospital in Thailand

Figures & data

Table 1 Demographic and Clinical Characteristics of All Study Patients in Cohort I (N = 353), and Compared Between CRE-Colonized Patients (N = 225) and CRE-Infected Patients (N = 128)

Characteristics	All Patients (N = 353)	CRE-Colonized Patients (N = 225)	CRE-Infected Patients (N = 128)	p-value
Male gender	183 (51.8%)	114 (50.7%)	69 (53.9%)	0.56
Age, mean±SD, (years)	66.7±17.8	68.5±17.5	63.6±18.0	0.01
Intensive care unit admission	62 (17.6%)	31 (13.8%)	31 (24.2%)	0.01
Comorbid conditions	328 (92.9%)	210 (93.3%)	118 (92.2%)	0.69
● Neurological disease	111 (31.4%)	73 (32.4%)	38 (29.7%)	0.59
● Diabetes mellitus	110 (31.2%)	70 (31.1%)	40 (31.3%)	0.98
● Chronic kidney disease	94 (26.6%)	59 (26.2%)	35 (27.3%)	0.82
● Cardiovascular disease	93 (26.3%)	66 (29.3%)	27 (21.1%)	0.09
● Solid malignancy	80 (22.7%)	46 (20.4%)	34 (26.6%)	0.19
● Chronic liver disease	42 (11.9%)	25 (11.1%)	17 (13.3%)	0.55
● Hematologic malignancy	37 (10.5%)	21 (9.3%)	16 (12.5%)	0.35
● Pulmonary disease	33 (9.3%)	26 (11.6%)	7 (5.5%)	0.06
● Autoimmune disease	24 (6.8%)	16 (7.1%)	8 (6.3%)	076
● Transplantation	9 (2.5%)	5 (2.2%)	4 (3.1%)	0.73
● HIV infection	7 (2.0%)	3 (1.3%)	4 (3.1%)	0.26
Prior use of immunosuppressive agents	117 (33.1%)	68 (30.2%)	49 (38.3%)	0.12
Prior use of antibiotics within the past 3 months before isolation of CRE	349 (98.9%)	223 (99.1%)	126 (98.4%)	0.62
● Beta-lactam/beta-lactamase inhibitors	225 (63.7%)	155 (68.9%)	70 (54.7%)	0.008
● Carbapenems	210 (59.5%)	133 (59.1%)	77 (60.2%)	0.85
● Cephalosporins	197 (55.8%)	127 (56.4%)	70 (54.7%)	0.75
● Fluoroquinolones	130 (36.8%)	84 (37.3%)	46 (35.9%)	0.79
● Vancomycin	110 (31.2%)	68 (30.2%)	42 (32.8%)	0.61
● Metronidazole	53 (15.0%)	37 (16.4%)	16 (12.5%)	0.32
● Colistin	52 (14.7%)	35 (15.6%)	17 (13.3%)	0.56
● Penicillins	26 (7.4%)	12 (5.3%)	14 (10.9%)	0.05
● Fosfomycin	21 (5.9%)	12 (5.3%)	9 (7.0%)	0.52
● Aminoglycosides	14 (4.0%)	8 (3.6%)	6 (4.7%)	0.60
Medical interventions	345 (97.7%)	221 (98.2%)	124 (96.9%)	0.47
● Urinary catheterization	319 (90.4%)	212 (94.2%)	107 (83.6%)	0.001
● Mechanical ventilation	205 (58.1%)	135 (60.0%)	70 (54.7%)	0.33
● Central venous catheterization	165 (46.7%)	102 (45.3%)	63 (45.3%)	0.48
● Major surgery	146 (41.4%)	94 (41.8%)	52 (40.6%)	0.83
● Renal replacement therapy	82 (23.2%)	46 (20.4%)	36 (28.1%)	0.10
● Parenteral nutrition	35 (9.9%)	20 (8.9%)	15 (11.7%)	0.39
Length of hospital stay, median (range), (days)	43.0 (4–421)	49 (4–359)	36 (4–421)	0.05
All-cause mortality at hospital discharge	134 (38.0%)	80 (35.6%)	54 (42.2%)	0.22

Note: *p-value<0.05 indicates statistical significance.

Abbreviations: CRE, carbapenem-resistant Enterobacterales; HIV, human immunodeficiency virus.

Table 2 Types of CRE Isolates in Clinical Specimens and Stool or Rectal Swab Samples of 353 Study Patients at Enrollment in Cohort I

Type of CRE*	Clinical Specimen, N (%)	Stool/Rectal Swab Specimen, N (%)
Number of CRE-positive specimens	353 (100%)	246 (69.7%)
● Klebsiella pneumoniae	271 (76.8%)	232 (65.7%)
● Escherichia coli	45 (12.7%)	48 (13.6%)
● Enterobacter spp.	46 (13.0%)	16 (4.5%)
● Citrobacter spp.	6 (1.7%)	0 (0.0%)

Note: *Some patients had more than one type of CRE.

Abbreviations: CRE, carbapenem-resistant Enterobacterales; spp., species.

Table 3 Characteristics and Natural History of 225 CRE-Colonized Patients

Characteristics	N (%)
Site of CRE colonization
● Urine	137 (60.9%)
● Sputum	95 (42.2%)
● Body fluid	21 (9.3%)
● Tissue	9 (1.3%)
Presence of CRE in stool or rectal swab samples at enrollment of study patients	152 (67.6%)
Status of 225 patients with CRE colonization during hospitalization
● Developed CRE infection	46 (20.4%)
● Site of CRE infection in 46 patients
● HAP/VAP	20 (43.5%)
● Urinary tract infection	14 (30.4%)
● Catheter-related blood stream infection	5 (10.8%)
● Intra-abdominal infection	3 (6.5%)
● Primary bacteremia	2 (4.3%)
● Skin and soft tissue infection	2 (4.3%)
● No CRE infection	179 (79.6%)
● CRE status at discharge of 69 patients who had ≥2 stool or rectal swab samples collected and had CRE in the initial stool or rectal swab sample
● Absence of CRE colonization before discharge	18 (26.1%)
● Presence of CRE colonization before discharge	51 (73.9%)

Abbreviations: CRE, carbapenem-resistant Enterobacterales; HAP, hospital-acquired pneumonia; VAP, ventilator-associated pneumonia.

Table 4 Clinical Characteristics Compared Between CRE-Colonized Patients Who Developed CRE Infection (N = 46) and Those Who Did Not Develop CRE Infection (N = 179)

Characteristics	Subsequent CRE Infection (N = 46), N (%)	No CRE Infection (N = 179), N (%)	p-value
Intensive care unit admission	12 (26.1%)	19 (10.6%)	0.007
Antibiotics used during hospitalization	46 (100.0%)	155 (86.6%)	0.006
● Penicillins	0 (0.0%)	3 (1.7%)	1.00
● Beta-lactams/beta-lactamase inhibitors	21 (45.7%)	65 (36.3%)	0.25
● Cephalosporins	3 (6.5%)	36 (20.1%)	0.03
● Fluoroquinolones	18 (39.1%)	35 (19.6%)	0.005
● Carbapenems	23 (50.0%)	65 (36.3%)	0.09
● Vancomycin	16 (34.8%)	36 (20.1%)	0.04
● Aminoglycosides	1 (2.2%)	4 (2.2%)	1.00
● Metronidazole	5 (10.9%)	14 (7.8%)	0.55
● Colistin	1 (2.2%)	16 (8.9%)	0.21
● Fosfomycin	0 (0.0%)	5 (2.8%)	0.59
● Tigecycline	1 (2.2%)	0 (0.0%)	0.20
Medical interventions	46 (100.0%)	175 (97.8%)	0.58
● Renal replacement therapy	15 (32.6%)	31 (17.3%)	0.02
● Central line catheterization	28 (60.9%)	74 (41.3%)	0.02
● Urinary catheterization	45 (97.8%)	167 (93.3%)	0.48
● Mechanical ventilation	37 (80.4%)	98 (54.7%)	0.002
● Major surgery	17 (37.0%)	77 (43.0%)	0.46
● Parenteral nutrition	5 (10.9%)	15 (8.4%)	0.57
Prior immunosuppressive drugs	15 (32.6%)	53 (29.6%)	0.69
Site of CRE colonization
● Stool	37 (80.4%)	115 (64.2%)	0.04
● Sputum	32 (69.6%)	63 (35.2%)	<0.001
● Urine	25 (54.3%)	112 (62.6%)	0.31
● Body fluid	6 (13.0%)	15 (8.4%)	0.39
● Tissue	2 (4.3%)	7 (3.9%)	1.00
● Multiple sites	40 (87.0%)	117 (65.4%)	0.004

Note: A p-value<0.05 indicates statistical significance.

Abbreviation: CRE, carbapenem-resistant Enterobacterales.

Table 5 Characteristics of and Clinical Course in 174 CRE-Infected Patients

Characteristics	N (%)
Site of infection
● Hospital-acquired pneumonia/ventilator-associated pneumonia	60 (34.5%)
● Urinary tract infection	51 (29.3%)
● Intra-abdominal infection	31 (17.8%)
● Primary bacteremia	13 (7.5%)
● Catheter-related blood stream infection	10 (5.7%)
● Skin and soft tissue infection	9 (5.2%)
Presence of CRE in stool samples at the time of enrollment	131 (75.3%)
Antibiotic regimens for treatment of CRE infection
● Monotherapy
● Colistin	34 (19.5%)
● Carbapenems	13 (7.5%)
● Aminoglycosides	7 (4.0%)
● Fosfomycin	4 (2.3%)
● Two-drug combination therapy
● Colistin and fosfomycin	64 (36.8%)
● Colistin and carbapenem	13 (7.5%)
● Aminoglycoside and fosfomycin	7 (4.0%)
● Colistin and tigecycline	6 (3.4%)
● Colistin and aminoglycoside	4 (2.3%)
● Aminoglycoside and carbapenem	2 (1.1%)
● Three-drug combination therapy
● Colistin, fosfomycin, and carbapenem	5 (2.9%)
● Colistin, fosfomycin, and aminoglycoside	3 (1.7%)
● Colistin, fosfomycin, and tigecycline	3 (1.7%)
● Colistin, aminoglycoside, and carbapenem	3 (1.7%)
● Four-drug combination therapy
● Colistin, fosfomycin, aminoglycoside, and carbapenem	2 (1.1%)
● Others	4 (2.3%)
Clinical outcome of CRE-infected patients
● Mortality at end of treatment	38 (21.8%)
● Mortality at discharge	83 (47.7%)
Microbiological response^a
● At the end of treatment in 141 patients	69 (48.9%)
CRE status at discharge of 83 patients who had ≥2 stool or rectal swab samples collected and had CRE in the initial stool or rectal swab sample
● Absence of CRE colonization before discharge	15 (18.1%)
● Presence of CRE colonization before discharge	68 (81.9%)

Note: ^aCRE was not isolated from follow-up specimens.

Abbreviation: CRE, carbapenem-resistant Enterobacterales.

Table 6 The Number and Percentage of Patients Having Risk Factors Significantly Associated with Mortality Compared Between Those Who Lived and Those Who Died Among 174 CRE-Infected Patients

Characteristics	Alive (N = 91), N (%)	Dead (N = 83), N (%)	p-value
Presence of CRE in stool samples at the time of enrollment	59 (64.8%)	72 (86.7%)	0.001
Site of infection
● Hospital-acquired pneumonia/ventilator-associated pneumonia	17 (18.7%)	43 (51.8%)	<0.001
● Urinary tract infection	39 (42.9%)	12 (14.5%)	<0.001
● Intra-abdominal infection	20 (22.0%)	11 (13.3%)	0.13
● Primary bacteremia	5 (5.5%)	8 (9.6%)	0.30
● Skin and soft tissue infection	7 (7.7%)	2 (2.4%)	0.17
Antibiotic regimens for treatment of CRE infection			0.75
● Monotherapy	35 (38.5%)	30 (36.1%)
● Combination therapy	56 (61.5%)	53 (63.9%)

Note: A p-value<0.05 indicates statistical significance.

Abbreviation: CRE, carbapenem-resistant Enterobacterales.