Predictors of mortality in solid organ transplant recipients with bloodstream infections due to carbapenemase-producing Enterobacterales: The impact of cytomegalovirus disease and lymphopenia

Elena Pérez-Nadales, Belén Gutiérrez-Gutiérrez, Alejandra M Natera, Edson Abdala, Maira Reina Magalhães, Alessandra Mularoni, Francesco Monaco, Ligia Camera Pierrotti, Maristela Pinheiro Freire, Ranganathan N Iyer, Seema Mehta Steinke, Elisa Grazia Calvi, Mario Tumbarello, Marco Falcone, Mario Fernández-Ruiz, José María Costa-Mateo, Meenakshi M Rana, Tania Mara Varejão Strabelli, Mical Paul, María Carmen Fariñas, Wanessa Trindade Clemente, Emmanuel Roilides, Patricia Muñoz, Laurent Dewispelaere, Belén Loeches, Warren Lowman, Ban Hock Tan, Rosa Escudero-Sánchez, Marta Bodro, Paolo Antonio Grossi, Fabio Soldani, Filiz Gunseren, Nina Nestorova, Álvaro Pascual, Luis Martínez-Martínez, José María Aguado, Jesús Rodríguez-Baño, Julián Torre-Cisneros, REIPI/INCREMENT-SOT Investigators, A T Wan Song, W Andraus, L A Carneiro D'Albuquerque, E David-Neto, F Jota de Paula, F Rossi, D Ostrander, R Avery, M Rizzi, A R Losito, F Raffaelli, P Del Giacomo, G Tiseo, J Lora-Tamayo, R San-Juan, I Gracia-Ahufinger, J Castón, Y A Ruiz, D R Altman, S V Campos, N Bar-Sinai, F Koppel, F Arnaiz de Las Revillas Almajano, C González Rico, M Fernández Martínez, P H O Mourão, F A Neves, J Ferreira, A Pyrpasopoulou, E Iosifidis, I Romiopoulos, M V Minero, C Sánchez-Carrillo, S Lardo, J Coussement, M Dodémont, K Jiayun, P Martín-Dávila, J Fortún, M Almela, A Moreno, L Linares, D D Gasperina, M L Balsamo, C Rovelli, E Concia, S Chiesi, D N Salerno, D Ogunc, B Pilmis, E M Seminari, J Carratalá, A Domínguez, E Cordero, J A Lepe, M Montejo, E Merino de Lucas, B M Eriksson, C van Delden, O Manuel, H Arslan, Z Koçak Tufan, E Kazak, M David, E Lease, N Nestorova, G Cornaglia, M Akova, Elena Pérez-Nadales, Belén Gutiérrez-Gutiérrez, Alejandra M Natera, Edson Abdala, Maira Reina Magalhães, Alessandra Mularoni, Francesco Monaco, Ligia Camera Pierrotti, Maristela Pinheiro Freire, Ranganathan N Iyer, Seema Mehta Steinke, Elisa Grazia Calvi, Mario Tumbarello, Marco Falcone, Mario Fernández-Ruiz, José María Costa-Mateo, Meenakshi M Rana, Tania Mara Varejão Strabelli, Mical Paul, María Carmen Fariñas, Wanessa Trindade Clemente, Emmanuel Roilides, Patricia Muñoz, Laurent Dewispelaere, Belén Loeches, Warren Lowman, Ban Hock Tan, Rosa Escudero-Sánchez, Marta Bodro, Paolo Antonio Grossi, Fabio Soldani, Filiz Gunseren, Nina Nestorova, Álvaro Pascual, Luis Martínez-Martínez, José María Aguado, Jesús Rodríguez-Baño, Julián Torre-Cisneros, REIPI/INCREMENT-SOT Investigators, A T Wan Song, W Andraus, L A Carneiro D'Albuquerque, E David-Neto, F Jota de Paula, F Rossi, D Ostrander, R Avery, M Rizzi, A R Losito, F Raffaelli, P Del Giacomo, G Tiseo, J Lora-Tamayo, R San-Juan, I Gracia-Ahufinger, J Castón, Y A Ruiz, D R Altman, S V Campos, N Bar-Sinai, F Koppel, F Arnaiz de Las Revillas Almajano, C González Rico, M Fernández Martínez, P H O Mourão, F A Neves, J Ferreira, A Pyrpasopoulou, E Iosifidis, I Romiopoulos, M V Minero, C Sánchez-Carrillo, S Lardo, J Coussement, M Dodémont, K Jiayun, P Martín-Dávila, J Fortún, M Almela, A Moreno, L Linares, D D Gasperina, M L Balsamo, C Rovelli, E Concia, S Chiesi, D N Salerno, D Ogunc, B Pilmis, E M Seminari, J Carratalá, A Domínguez, E Cordero, J A Lepe, M Montejo, E Merino de Lucas, B M Eriksson, C van Delden, O Manuel, H Arslan, Z Koçak Tufan, E Kazak, M David, E Lease, N Nestorova, G Cornaglia, M Akova

Abstract

Treatment of carbapenemase-producing Enterobacterales bloodstream infections in solid organ transplant recipients is challenging. The objective of this study was to develop a specific score to predict mortality in solid organ transplant recipients with carbapenemase-producing Enterobacterales bloodstream infections. A multinational, retrospective (2004-2016) cohort study (INCREMENT-SOT, ClinicalTrials.gov NCT02852902) was performed. The main outcome variable was 30-day all-cause mortality. The INCREMENT-SOT-CPE score was developed using logistic regression. The global cohort included 216 patients. The final logistic regression model included the following variables: INCREMENT-CPE mortality score ≥8 (8 points), no source control (3 points), inappropriate empirical therapy (2 points), cytomegalovirus disease (7 points), lymphopenia (4 points), and the interaction between INCREMENT-CPE score ≥8 and CMV disease (minus 7 points). This score showed an area under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI] 0.76-0.88) and classified patients into 3 strata: 0-7 (low mortality), 8-11 (high mortality), and 12-17 (very-high mortality). We performed a stratified analysis of the effect of monotherapy vs combination therapy among 165 patients who received appropriate therapy. Monotherapy was associated with higher mortality only in the very-high (adjusted hazard ratio [HR] 2.82, 95% CI 1.13-7.06, P = .03) and high (HR 9.93, 95% CI 2.08-47.40, P = .004) mortality risk strata. A score-based algorithm is provided for therapy guidance.

Keywords: antibiotic drug resistance; clinical research/practice; infection and infectious agents - bacterial; infectious disease; organ transplantation in general.

© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.

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Source: PubMed

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