Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum beta-lactamase-producing Enterobacteriaceae

François Barbier , Sébastien Bailly , Carole Schwebel (1) , Laurent Papazian (2) , Élie Azoulay (3) , Hatem Kallel (4) , Shidasp Siami (5) , Laurent Argaud (6, 7) , Guillaume Marcotte (8) , Beno\ⁱt Misset , Jean Reignier (9) , Michaël Darmon (10) , Jean-Ralph Zahar (11, 12) , Dany Goldgran-Toledano , Étienne De Montmollin , Bertrand Souweine (13) , Bruno Mourvillier (14) , Jean-François Timsit

1 Clinique de réanimation médicale
2 Hôpitaux Sud - Hôpital Sainte-Marguerite [CHU - APHM]
3 Hôpital Saint-Louis
4 Centre Hospitalier Andrée Rosemon [Cayenne, Guyane Française]
5 Hôpital Sud Francilien Corbeil-Essonnes
6 HCL - Hospices Civils de Lyon
7 CarMeN - Cardiovasculaire, métabolisme, diabétologie et nutrition
8 Hôpital Edouard Herriot [CHU - HCL]
9 Service d'anesthésie et réanimation chirurgicale [Nantes]
10 Urg - SAINT ETIENNE - Service des Urgences et de Réanimation Médicale
11 Hôpital Avicenne [AP-HP]
12 IAME (UMR_S_1137 / U1137) - Infection, Anti-microbiens, Modélisation, Evolution
13 LMGE - Laboratoire Microorganismes : Génome et Environnement
14 Service de réanimation médicale et infectieuse

Purpose: To investigate the clinical significance of infection-related ventilator-associated complications (IVAC) and their impact on carbapenem consumption in mechanically ventilated (MV) patients colonised with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE). Methods: Inception cohort study from the French prospective multicenter OUTCOMEREA database (17 ICUs, 1997-2015) including all ESBLE carriers (systematic rectal swabbing at admission then weekly and/or urinary or superficial surgical site colonisation) with MV duration \textgreater 48 h and \textgreater= 1 episode of IVAC after carriage documentation. All ICU-acquired infections were microbiologically documented. Results: The 318 enrolled ESBLE carriers (median age 68 years; males 67%; medical admission 68%; imported carriage 53%) experienced a total of 576 IVAC comprising 361 episodes (63%) without documented infection, 124 (21%) related to infections other than ventilator-associated pneumonia (VAP), 73 (13%) related to non-ESBLE VAP and 18 (3%) related to ESBLE VAP. Overall, ESBLE infections accounted for only 43 episodes (7%). Carbapenem exposure within the preceding 3 days was the sole independent predictor of ESBLE infection as the causative event of IVAC, with a protective effect (adjusted odds ratio 0.2, 95% confidence interval 0.05-0.6; P \textless 0.01). Carbapenems were initiated in 9% of IVAC without infection, 15% of IVAC related to non-VAP infections, 42% of IVAC related to non-ESBLE VAP, and 56% of IVAC related to ESBLE VAP (ESBLE VAP versus non-ESBLE VAP: P = 0.43). Conclusions: IVAC in ESBLE carriers mostly reflect noninfectious events but act as a strong driver of empirical carbapenem consumption. ESBLE infections are scarce yet hard to predict, strengthening the need for novel diagnostic approaches and carbapenem-sparing alternatives.

Mots clés: antibiotic-therapy; Outcome; General & Internal Medicine; antimicrobial resistance; bacteria; Carbapenem; Extended-spectrum beta-lactamase; gram-negative bacilli; intensive-care units; Mechanical ventilation; metaanalysis; pneumonia; strategies; surveillance; urinary-tract-infections; Ventilator-associated pneumonia

Domaines: Sciences du Vivant [q-bio]

François Barbier, Sébastien Bailly, Carole Schwebel, Laurent Papazian, Élie Azoulay, et al.. Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum beta-lactamase-producing Enterobacteriaceae. Intensive Care Medicine, 2018, 44 (5), pp.616-626. ⟨10.1007/s00134-018-5154-4⟩. ⟨hal-01847386⟩