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Resistant E. coli, E. faecium CLABSIs prevalent among oncology settings
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Data reported to the CDC indicated that central line-associated bloodstream infections, or CLABSIs, resulting from fluoroquinolone-resistant Escherichia coli and vancomycin-resistant Enterococcus faecium are occurring more frequently among adult oncology care facilities.
“Preventing [bloodstream infections] and associated complications is … a critical patient safety issue and has motivated the creation of clinical practice guidelines for antibiotic prophylaxis and empiric treatment of neutropenic cancer patients with fever,” the researchers wrote. “Oncology patient populations might be uniquely and more severely affected by emerging antimicrobial-resistant threats.”
Reports from single centers have suggested increased resistance among gram-negative pathogens associated with fluoroquinolone prophylaxis, but evidence suggesting a wider trend among oncology units previously was unavailable. To rectify this gap in knowledge, researchers examined national CLABSI events reported to the CDC’s National Healthcare Safety Network (NHSN) from 2009 to 2012. Cases reported from a variety of hematology/oncology locations were categorized by pathogen profile, including the presence of several antimicrobial resistances. Researchers calculated overall and categorical CLABSI incidence rates per 1,000 central line-days, and compared these with case and incidence rates reported from all other nononcology inpatient units.
There were 4,654 CLABSI reported to NHSN from 299 adult oncology units during the study period, the researchers wrote, with nearly three times as many locations reporting cases in 2012 than in 2009. The most commonly reported CLABSI organisms were coagulase-negative staphylococci (16.9%), E. coli (11.8%), E. faecium (11.4%) and S. aureus (10%). The organism profiles of CLABSIs differed between oncology and nononcology units, however, with E. coli, E. faecium and viridans group streptococci comprising 29% of oncology unit CLABSI as opposed to 12% of nononcology CLABSI (P < .0001).
The researchers also observed significant discrepancies in antimicrobial resistance rates between settings. Among oncology units, they noted greater rates of fluoroquinolone-resistant E. coli (rate ratio = 7.37; 95% CI, 6.2-8.76) and vancomycin-resistant E. faecium (rate ratio = 2.27; 95% CI, 2.03-2.53), but lower rates of resistant Pseudomonas aeruginosa and Klebsiella pneumoniae and K. oxytoca. Resistance rates remained relatively stable throughout the study period, with only fluoroquinolone-resistant E. coli becoming more prevalent from 2009-2010 to 2011-2012 (49.5% vs. 60.4%; P = .01).
“Our analysis shows that fluoroquinolone-resistant E. coli and vancomycin-resistant E. faecium are common antimicrobial-resistant pathogens in adult inpatient oncology locations, particularly when compared to nononcology locations,” the researchers wrote. “These findings are of concern given the fluoroquinolone-resistant E. coli infections are associated with increased mortality in oncology patients.
“Contemporary data regarding the prevalence of resistant pathogens could better define this impact moving forward.” – by Dave Muoio
Disclosure: See reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
Back to TopThe report of higher rates of CLABSI with fluoroquinolone (FQ)-resistant E. coli and vancomycin-resistant E. faecium (VRE) is concerning, and reports of increasing resistance rates are worthy of further investigation. The differential spectrum of organisms seen in hematology/oncology patients (E. coli, strep viridans, and VRE) compared with the general population is most likely a representation of the result of mucositis secondary to cytotoxic chemotherapy, leading to GI translocation in this setting. Thus, many of the CLABSI may be better characterized as mucosal barrier injury laboratory-confirmed bloodstream infections. Nonetheless, the possible increased resistance rates demand attention to antibiotic use patterns in hematology/oncology patients, in particular, overuse of vancomycin and the use of FQ prophylaxis.
Excessive vancomycin use likely contributes to the increasing rate of VRE in hematology/oncology patients. This should continue to drive stewardship efforts to utilize vancomycin only in hematology/oncology patients with true indications for therapy per National Comprehensive Cancer Network guidelines (eg, patients with cellulitis, patients with clinically apparent serious IV catheter infections, and septic patients). Data regarding the impact of FQ prophylaxis in hematology/oncology patients is conflicting; thus, local epidemiology patterns should guide possible use of prophylaxis in patients at highest risk for gram-negative infections and poor outcomes. For example, our center restricts the use of FQ to patients with relapsed/refractory leukemias based upon a high rate of gram-negative bacteremias and has not experienced an increase in FQ-resistance or other adverse consequences; in contrast, gram-negative infections have significantly declined.
Finally, the continuously changing epidemiology and resistance patterns in our hematology/oncology patients have caused all of us to re-examine our infectious diseases treatment guidelines, including febrile neutropenia practices. A “one-regimen-fits-all” approach to management of febrile neutropenia soon may no longer be appropriate. Rapid diagnostic testing (eg, Verigene, MALDI-TOF) and novel studies that seek to identify risk factors for these resistant organisms can aid in better tailoring empiric therapy (eg, addition of linezolid, daptomycin for VRE and use of carbapenems or amikacin for resistant gram negatives) in specific hematology/oncology patients at highest risk for resistance to specific organisms.
Bernard L. Marini, PharmD
Department of Pharmacy Services,
University of Michigan Health System
Anthony J. Perissinotti, PharmD, BCOP
Department of Pharmacy Services,
University of Michigan Health System
Dale L. Bixby, MD, PhD
Department of Internal Medicine, Division of Hematology and Oncology,
University of Michigan Health System
References:
Bucaneve G, et al. N Engl J Med. 2005;doi:10.1056/NEJMoa044097.
Epstein L, et al. Infect Control Hosp Epidemiol. 2016;doi:10.1017/ice.2015.245.
Marini BL, et al. Support Care Cancer. 2015;doi:10.1007/s00520-014-2582-8.
Rosa RG. Am J Infect Control. 2014;doi:10.1016/j.ajic.2013.06.025.
Verlinden A, et al. Eur J Haematol. 2014;doi:10.1111/ejh.12345.
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