Bloodstream infections in adult patients with malignancy, epidemiology, microbiology, and risk factors associated with mortality and multi-drug resistance

Ali Amanati, Sarvin Sajedianfard, Somayeh Khajeh, Shabnam Ghasempour, Salma Mehrangiz, Samane Nematolahi, Zahra Shahhosein, Ali Amanati, Sarvin Sajedianfard, Somayeh Khajeh, Shabnam Ghasempour, Salma Mehrangiz, Samane Nematolahi, Zahra Shahhosein

Abstract

Background: This study aimed to investigate the epidemiology, microbiology, and risk factors associated with mortality and multi-drug resistance bacterial bloodstream infections (BSIs) among adult cancer patients in Shiraz, Iran. We also report a four-year trend of antimicrobial resistance patterns of BSIs.

Methods: We conducted a retrospective study at a referral oncology hospital from July 2015 to August 2019, which included all adults with confirmed BSI.

Results: 2393 blood cultures tested during the four-year study period; 414 positive cultures were included. The mean age of our patients was 47.57 ± 17.46 years old. Central Line-Associated BSI (CLABSI) was more common in solid tumors than patients with hematological malignancies. Gram-negative (GN) bacteria were more detected (63.3%, 262) than gram-positive bacteria (36.7%, 152). Escherichia coli was the most common gram-negative organism (123/262, 47%), followed by Pseudomonas spp. (82/262, 31%) and Klebsiella pneumoniae (38/262, 14.5%). Coagulase-negative staphylococci (CoNS) was the most frequently isolated pathogen among gram-positive bacteria (83/152, 54.6%). Acinetobacter spp., Pseudomonas spp., E. coli, and K. pneumoniae were the most common Extended-Spectrum Beta-Lactamase (ESBL) producers (100, 96.2, 66.7%, and 60.7, respectively). Acinetobacter spp., Pseudomonas spp., Enterobacter spp., E. coli, and K. pneumoniae were the most common carbapenem-resistant (CR) isolates (77.8, 70.7, 33.3, 24.4, and 13.2%, respectively). Out of 257 Enterobacterales and non-fermenter gram-negative BSIs, 39.3% (101/257) were carbapenem-resistant. Although the incidence of multi-drug resistance (MDR) gram-negative BSI increased annually during 2015-2018, the mortality rate of gram-negative BSI remains unchanged at about 20% (p-value = 0.55); however, the mortality rate was significantly greater (35.4%) in those with resistant gram-positive BSI (p-value = 0.001). The overall mortality rate was 21.5%. Early (7-day mortality) and late mortality rate (30-day mortality) were 10 and 3.4%, respectively.

Conclusions: The emergence of MDR gram-negative BSI is a significant healthcare problem in oncology centers. The high proportion of the most frequently isolated pathogens were CR and ESBL-producing Enterobacterales and Pseudomonas spp. We have few effective choices against MDRGN BSI, especially in high-risk cancer patients, which necessitate newer treatment options.

Keywords: Bloodstream infection; Cancer; Carbapenem-resistant isolates; Extended-Spectrum Beta-lactamase producing pathogens; Mortality; Multidrug-resistant gram-negative infection.

Conflict of interest statement

The authors do not have any financial or other relationships, which could regard as a conflict of interest.

Figures

Fig. 1
Fig. 1
Flow chart of study population screened and enrolled associated with bloodstream infections caused by gram-negative and gram-positive bacteria in patients treated at the Amir oncology hospital between July 2015 to August 2019
Fig. 2
Fig. 2
Incidence of febrile neutropenia, bloodstream infections, mortality rate/10000 cases, and hospitalized adults with cancer during 2015–2019. FN: febrile neutropenia episodes; BSI: bloodstream infection
Fig. 3
Fig. 3
The percentage frequency distribution of different gram-negative and gram-positive bacteria isolated from blood cultures
Fig. 4
Fig. 4
The annual frequency of ESBL and CRE-associated BSI, in addition to MRCoNS, associated BSI (labels represent case numbers). CRGN includes carbapenem resistance Enterobacterales and non-fermenter spp.
Fig. 5
Fig. 5
Antimicrobial susceptibility results of 123 E. coli (A) and 81 Pseudomonas spp. (B) isolates recovered from blood cultures during 2015–2019
Fig. 6
Fig. 6
Antimicrobial susceptibility results of 38 K. pneumonia (A) and of 80 coagulase-negative staphylococci (CoNS) isolates (B) recovered from blood cultures during 2015–2019
Fig. 7
Fig. 7
Comparative analysis for antibiotic resistance rate between E. coli, K. pneumoniae, and Pseudomonas spp. with all gram-negative isolates (A, B, and C, respectively)

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