- Email: [email protected]
Community-onset bacteraemia caused by fluoroquinolone-resistant Klebsiella pneumoniae: clinical epidemiology and risk factors
Letters to the Editor / International Journal of Antimicrobial Agents 39 (2012) 177–185
be a therapeutic option for cases of infection caused by MDR A. baumannii [5]. Moreover, it has been shown that patients infected with A. baumannii, including strains resistant to carbapenems, improved or were cured upon treatment with sulbactam alone or in combination with other antibiotics [1]. Despite the lack of well controlled clinical studies, these results suggest that sulbactam may be considered as a good option, in association with colistin, in the treatment of MDR A. baumannii infections, especially for infections caused by A. baumannii resistant to imipenem. In conclusion, increasing use of colistin for treating infections due to MDR A. baumannii worldwide will inevitably increase the recovery rate of colistin-resistant isolates in the future. Although the optimum treatment is not currently well established for MDR A. baumannii infections, antibiotic combination with sulbactam may provide significant benefit over monotherapy and improve the chance of survival. We believe that the MIC against sulbactam should be systematically determined for carbapenem-resistant A. baumannii and sulbactam added to colistin in the treatment of patients to avoid the emergence of colistin-resistant A. baumannii strains, as recently exemplified in France and Spain [2,3]. Funding: This work was partly funded by the Centre national de la recherche scientifique (CNRS). Competing interests: None declared. Ethical approval: Not required. References [1] Peleg AY, Seifert H, Paterson DL. Acinetobacter baumannii: emergence of a successful pathogen. Clin Microbiol Rev 2008;21:538–82. [2] Rolain JM, Roch A, Castanier M, Papazian L, Raoult D. Acinetobacter baumannii resistant to colistin with impaired virulence: a case report from France. J Infect Dis 2011;204:1146–7. [3] López-Rojas R, Jiménez-Mejías ME, Lepe JA, Pachón J. Acinetobacter baumannii resistant to colistin alters its antibiotic resistance profile: a case report from Spain. J Infect Dis 2011;204:1147–8. [4] López-Rojas R, Domínguez-Herrera J, McConnell MJ, Docobo-Peréz F, Smani Y, Fernández-Reyes M, et al. Impaired virulence and in vivo fitness of colistinresistant Acinetobacter baumannii. J Infect Dis 2011;203:545–8. [5] Higgins PG, Wisplinghoff H, Stefanik D, Seifert H. In vitro activities of the -lactamase inhibitors clavulanic acid, sulbactam, and tazobactam alone or in combination with -lactams against epidemiologically characterized multidrug-resistant Acinetobacter baumannii strains. Antimicrob Agents Chemother 2004;48:1586–92.
Marie Kempf Lamia Djouhri-Bouktab Jean-Michel Brunel Didier Raoult Jean-Marc Rolain ∗ Aix-Marseille Université, URMITE CNRS-IRD, UMR 6236, Faculté de Médecine et de Pharmacie, Université de la Méditerranée Aix-Marseille-II, 27 Bd Jean Moulin, 13385 Marseille cedex 05, France ∗ Corresponding
author. Tel.: +33 4 91 32 43 75; fax: +33 4 91 38 77 72. E-mail address: [email protected] (J.-M. Rolain) 29 September 2011 doi:10.1016/j.ijantimicag.2011.10.001
Community-onset bacteraemia caused by fluoroquinoloneresistant Klebsiella pneumoniae: clinical epidemiology and risk factors Sir, Despite the high prevalence of antimicrobial-resistant Klebsiella pneumoniae in hospital-acquired infections, the clinical epidemiology of fluoroquinolone (FQ) resistance in community-onset K. pneumoniae bacteraemia is not well understood. This study
181
was performed to evaluate the clinical features and risk factors for community-onset FQ-resistant K. pneumoniae bacteraemia amongst patients admitted to the Emergency Department. The medical records of individuals diagnosed with K. pneumoniae bacteraemia between January 2006 and September 2009 at Samsung Medical Centre (Seoul, South Korea), a 1950-bed tertiary care university hospital, were reviewed. Cases available from the database of a nationwide bacteraemia surveillance study performed from October 2006 to September 2007 were also included in the analysis [1]. Only adult patients (≥16 years) were included and the first episode for each patient was included in the analysis. This study sample has been previously described in detail [1,2]. The clinical features of patients with FQ-resistant and FQsusceptible K. pneumoniae bacteraemias were compared. Antibiotic susceptibility testing and extended-spectrum -lactamase (ESBL) confirmatory testing were performed using the VITEK II automated system (bioMérieux, Hazelwood, MO) by the standard modified broth microdilution method following the recommendations of the Clinical and Laboratory Standards Institute (CLSI). Infections diagnosed within the first 48 h of hospitalisation were classified as community-onset infections, based on the time at which culture samples were obtained. Community-onset infection was further classified as community-associated or healthcare-associated, as previously suggested [2,3]. Student’s t-test was used to compare continuous variables, and 2 or Fisher’s exact test was used to compare categorical variables. A backward stepwise logistic regression analysis was performed to identify independent risk factors for FQ resistance. All P-values were two-tailed and a P-value of <0.05 was considered statistically significant. Of 414 patients with community-onset K. pneumoniae bacteraemia, 40 (9.7%) had FQ-resistant K. pneumoniae bacteraemia and 374 (90.3%) had FQ-susceptible K. pneumoniae bacteraemia. Of the 40 cases of FQ-resistant bacteraemia, 24 (60%) were classified as healthcare-associated, whilst 138 (36.9%) of the 374 cases of FQ-susceptible bacteraemia (P = 0.004) were classified as healthcare-associated. Risk factors associated with communityonset FQ-resistant K. pneumoniae bacteraemia are described in Table 1. Multivariate analysis was performed to identify predictors of FQ resistance in community-onset K. pneumoniae bacteraemia; those found included prior use of antibiotics within 1 month [odds ratio (OR) = 5.74, 95% confidence interval (CI) 2.71–12.16], tube insertion (OR = 4.44, 95% CI 1.35–14.59), urinary tract infection (UTI) (OR = 3.34, 95% CI 1.41–7.93) and healthcare-associated infection (OR = 2.36, 95% CI 1.14–4.91). Further multivariate analysis using data on prior receipt of FQs or cephalosporins, which were available for 326 patients (excluding 9 patients who only had information on cephalosporin treatment), showed that each of these antibiotics was significantly associated with FQ-resistant K. pneumoniae bacteraemia, as were tube insertion, indwelling urinary catheter, UTI and healthcare-associated infection (all P < 0.05). Subgroup analysis was performed for 252 patients with community-associated K. pneumoniae bacteraemia (excluding healthcare-associated infections). Univariate analysis revealed significant relationships between FQ-resistant K. pneumoniae bacteraemia and age ≥65 years, tube insertion and prior use of antibiotics (all P < 0.05). Multivariate analysis showed that prior use of antibiotics (OR = 5.95, 95% CI 1.99–17.79), UTI (OR = 3.46, 95% CI 1.03–11.56) and age ≥65 years (OR = 3.30, 95% CI 1.00–10.89) were independently associated with FQ resistance in communityassociated K. pneumoniae bacteraemia. ESBLs were detected in 25 (62.5%) of the 40 FQ-resistant K. pneumoniae isolates, whilst only 13 (3.5%) of 374 FQ-susceptible K. pneumoniae isolates were ESBLproducers. Although previous studies described the clinical and microbiological epidemiology of FQ-resistant Escherichia coli infections, particularly in the urinary tract, the risk factors for infections with
182
Letters to the Editor / International Journal of Antimicrobial Agents 39 (2012) 177–185
Table 1 Clinical characteristics of community-onset bacteraemias caused by fluoroquinolone (FQ)-resistant and FQ-susceptible Klebsiella pneumoniae.a Characteristic
FQ-resistant (n = 40)
FQ-susceptible (n = 374)
P-value
Age (years) (mean ± S.D.) Old age (≥65 years) Male Healthcare-associated infection ESBL-producing isolates Underlying disease Solid tumour Haematological malignancy Cardiovascular disease Liver disease Renal disease Neurological disease Diabetes mellitus Co-morbid conditions Recent operation within 1 month Immunosuppressant use Neutropenia Corticosteroid use Indwelling urinary catheter Tube insertionb Prior use of antibiotics within 1 month Cephalosporin Fluoroquinolone Site of infection Primary bacteraemia Pneumonia Urinary tract infection Intra-abdominal infection Severe sepsis Pitt bacteraemia score (mean ± S.D.)
61.7 ± 18.0 19 (47.5) 29 (72.5) 24 (60.0)
62.2 ± 14.3 176 (47.1) 226 (60.4) 138 (36.9)
25 (62.5)
13 (3.5)
19 (47.5) 6 (15.0)
148 (39.6) 25 (6.7)
0.331 0.103
9 (22.5) 7 (17.5) 3 (7.5) 7 (17.5) 11 (27.5)
92 (24.6) 90 (24.1) 20 (5.3) 34 (9.1) 91 (24.3)
0.769 0.352 0.477 0.097 0.658
6 (15.0)
18 (4.8)
0.020
7 (17.5) 6 (15.0) 3 (7.5) 5 (12.5) 6 (15.0) 25 (62.5)
55 (14.7) 40 (10.7) 6 (1.6) 18 (4.8) 10 (2.7) 76 (20.3)
0.638 0.425 0.047 0.059 0.002 <0.001
15/34 (44.1) 7/34 (20.6)
43/301 (14.3) 11/292 (3.8)
<0.001 <0.001
9 (22.5) 2 (5.0) 10 (25.0) 15 (37.5) 14/40 (35.0) 1.11 ± 1.98
49 (13.1) 37 (9.9) 52 (13.9) 201 (53.7) 150/371 (40.4) 1.71 ± 2.33
0.104 0.406 0.062 0.051 0.505 0.122
0.815 0.958 0.136 0.004
challenge for clinicians and the current data are especially useful in empirical antimicrobial therapy for community-onset infections. Funding: This study was supported by a Basic Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (No. 20100021572). Competing interests: None declared. Ethical approval: This study was approved by the Institutional Review Board of Samsung Medical Center (Seoul, South Korea).
<0.001
References
S.D., standard deviation; ESBL, extended-spectrum -lactamase. a Data are presented as number (%) of patients, unless otherwise stated. b Nasogastric tube or percutaneous tube.
FQ-resistant pathogens, particularly K. pneumoniae, in the community setting are rarely reported. In this study, we found several variables in healthcare-associated infections that were significantly associated with FQ resistance in community-onset K. pneumoniae bacteraemia. Subgroup analysis of the community-associated K. pneumoniae bacteraemias (excluding healthcare-associated infections) showed that prior use of antibiotics, UTI and age ≥65 years were significantly associated with FQ resistance. These findings suggest that FQ resistance in community-onset K. pneumoniae bacteraemia may be largely associated with the healthcare setting. In this study, 60% of FQ-resistant K. pneumoniae isolates were ESBL-positive compared with 3.5% of FQ-susceptible isolates. This supports a previously observed negative association between FQ susceptibility in E. coli and K. pneumoniae and ESBL production [4,5]. Consistent with those previous studies, we found FQ resistance to be closely related to ESBL-positivity amongst community-onset K. pneumoniae bacteraemias. In conclusion, FQ-resistant K. pneumoniae is a significant cause of community-onset bacteraemia, with relation to healthcareassociated infections. Community-onset FQ-resistant K. pneumoniae bacteraemia was associated with prior use of antibiotics and several other factors associated with healthcare-associated infections. In community-associated infections, prior use of antibiotics, UTI and old age (≥65 years) were independently associated with FQ resistance. Determining the optimal antimicrobial therapy in community-onset K. pneumoniae bacteraemia is now becoming a
[1] Kang CI, Song JH, Chung DR, Peck KR, Ko KS, Yeom JS, et al. Risk factors and pathogenic significance of severe sepsis and septic shock in 2286 patients with Gram-negative bacteremia. J Infect 2011;62:26–33. [2] Lee JA, Kang CI, Joo EJ, Ha YE, Kang SJ, Park SY, et al. Epidemiology and clinical features of community-onset bacteremia caused by extendedspectrum -lactamase-producing Klebsiella pneumoniae. Microb Drug Resist 2011;17:267–73. [3] Friedman ND, Kaye KS, Stout JE, McGarry SA, Trivette SL, Briggs JP, et al. Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 2002;137:791–7. [4] Tolun V, Küc¸ükbasmaci O, Törümküney-Akbulut D, Catal C, An˘g-Küc¸üker M, An˘g O. Relationship between ciprofloxacin resistance and extended-spectrum -lactamase production in Escherichia coli and Klebsiella pneumoniae strains. Clin Microbiol Infect 2004;10:72–5. [5] van der Starre WE, van Nieuwkoop C, Paltansing S, Van’t Wout JW, Groeneveld GH, Becker MJ, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother 2011;66:650–6.
Cheol-In Kang ∗ Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea Jeong-A. Lee a,b Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea b Division of Infectious Diseases, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea a
Yu Mi Wi Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea Doo Ryeon Chung Kyong Ran Peck Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea Nam Yong Lee Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Jae-Hoon Song Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea ∗ Corresponding
author. Tel.: +82 2 3410 0324; fax: +82 2 3410 0064. E-mail addresses: [email protected], [email protected] (C.-I. Kang) 21 June 2011 doi:10.1016/j.ijantimicag.2011.09.025
be a therapeutic option for cases of infection caused by MDR A. baumannii [5]. Moreover, it has been shown that patients infected with A. baumannii, including strains resistant to carbapenems, improved or were cured upon treatment with sulbactam alone or in combination with other antibiotics [1]. Despite the lack of well controlled clinical studies, these results suggest that sulbactam may be considered as a good option, in association with colistin, in the treatment of MDR A. baumannii infections, especially for infections caused by A. baumannii resistant to imipenem. In conclusion, increasing use of colistin for treating infections due to MDR A. baumannii worldwide will inevitably increase the recovery rate of colistin-resistant isolates in the future. Although the optimum treatment is not currently well established for MDR A. baumannii infections, antibiotic combination with sulbactam may provide significant benefit over monotherapy and improve the chance of survival. We believe that the MIC against sulbactam should be systematically determined for carbapenem-resistant A. baumannii and sulbactam added to colistin in the treatment of patients to avoid the emergence of colistin-resistant A. baumannii strains, as recently exemplified in France and Spain [2,3]. Funding: This work was partly funded by the Centre national de la recherche scientifique (CNRS). Competing interests: None declared. Ethical approval: Not required. References [1] Peleg AY, Seifert H, Paterson DL. Acinetobacter baumannii: emergence of a successful pathogen. Clin Microbiol Rev 2008;21:538–82. [2] Rolain JM, Roch A, Castanier M, Papazian L, Raoult D. Acinetobacter baumannii resistant to colistin with impaired virulence: a case report from France. J Infect Dis 2011;204:1146–7. [3] López-Rojas R, Jiménez-Mejías ME, Lepe JA, Pachón J. Acinetobacter baumannii resistant to colistin alters its antibiotic resistance profile: a case report from Spain. J Infect Dis 2011;204:1147–8. [4] López-Rojas R, Domínguez-Herrera J, McConnell MJ, Docobo-Peréz F, Smani Y, Fernández-Reyes M, et al. Impaired virulence and in vivo fitness of colistinresistant Acinetobacter baumannii. J Infect Dis 2011;203:545–8. [5] Higgins PG, Wisplinghoff H, Stefanik D, Seifert H. In vitro activities of the -lactamase inhibitors clavulanic acid, sulbactam, and tazobactam alone or in combination with -lactams against epidemiologically characterized multidrug-resistant Acinetobacter baumannii strains. Antimicrob Agents Chemother 2004;48:1586–92.
Marie Kempf Lamia Djouhri-Bouktab Jean-Michel Brunel Didier Raoult Jean-Marc Rolain ∗ Aix-Marseille Université, URMITE CNRS-IRD, UMR 6236, Faculté de Médecine et de Pharmacie, Université de la Méditerranée Aix-Marseille-II, 27 Bd Jean Moulin, 13385 Marseille cedex 05, France ∗ Corresponding
author. Tel.: +33 4 91 32 43 75; fax: +33 4 91 38 77 72. E-mail address: [email protected] (J.-M. Rolain) 29 September 2011 doi:10.1016/j.ijantimicag.2011.10.001
Community-onset bacteraemia caused by fluoroquinoloneresistant Klebsiella pneumoniae: clinical epidemiology and risk factors Sir, Despite the high prevalence of antimicrobial-resistant Klebsiella pneumoniae in hospital-acquired infections, the clinical epidemiology of fluoroquinolone (FQ) resistance in community-onset K. pneumoniae bacteraemia is not well understood. This study
181
was performed to evaluate the clinical features and risk factors for community-onset FQ-resistant K. pneumoniae bacteraemia amongst patients admitted to the Emergency Department. The medical records of individuals diagnosed with K. pneumoniae bacteraemia between January 2006 and September 2009 at Samsung Medical Centre (Seoul, South Korea), a 1950-bed tertiary care university hospital, were reviewed. Cases available from the database of a nationwide bacteraemia surveillance study performed from October 2006 to September 2007 were also included in the analysis [1]. Only adult patients (≥16 years) were included and the first episode for each patient was included in the analysis. This study sample has been previously described in detail [1,2]. The clinical features of patients with FQ-resistant and FQsusceptible K. pneumoniae bacteraemias were compared. Antibiotic susceptibility testing and extended-spectrum -lactamase (ESBL) confirmatory testing were performed using the VITEK II automated system (bioMérieux, Hazelwood, MO) by the standard modified broth microdilution method following the recommendations of the Clinical and Laboratory Standards Institute (CLSI). Infections diagnosed within the first 48 h of hospitalisation were classified as community-onset infections, based on the time at which culture samples were obtained. Community-onset infection was further classified as community-associated or healthcare-associated, as previously suggested [2,3]. Student’s t-test was used to compare continuous variables, and 2 or Fisher’s exact test was used to compare categorical variables. A backward stepwise logistic regression analysis was performed to identify independent risk factors for FQ resistance. All P-values were two-tailed and a P-value of <0.05 was considered statistically significant. Of 414 patients with community-onset K. pneumoniae bacteraemia, 40 (9.7%) had FQ-resistant K. pneumoniae bacteraemia and 374 (90.3%) had FQ-susceptible K. pneumoniae bacteraemia. Of the 40 cases of FQ-resistant bacteraemia, 24 (60%) were classified as healthcare-associated, whilst 138 (36.9%) of the 374 cases of FQ-susceptible bacteraemia (P = 0.004) were classified as healthcare-associated. Risk factors associated with communityonset FQ-resistant K. pneumoniae bacteraemia are described in Table 1. Multivariate analysis was performed to identify predictors of FQ resistance in community-onset K. pneumoniae bacteraemia; those found included prior use of antibiotics within 1 month [odds ratio (OR) = 5.74, 95% confidence interval (CI) 2.71–12.16], tube insertion (OR = 4.44, 95% CI 1.35–14.59), urinary tract infection (UTI) (OR = 3.34, 95% CI 1.41–7.93) and healthcare-associated infection (OR = 2.36, 95% CI 1.14–4.91). Further multivariate analysis using data on prior receipt of FQs or cephalosporins, which were available for 326 patients (excluding 9 patients who only had information on cephalosporin treatment), showed that each of these antibiotics was significantly associated with FQ-resistant K. pneumoniae bacteraemia, as were tube insertion, indwelling urinary catheter, UTI and healthcare-associated infection (all P < 0.05). Subgroup analysis was performed for 252 patients with community-associated K. pneumoniae bacteraemia (excluding healthcare-associated infections). Univariate analysis revealed significant relationships between FQ-resistant K. pneumoniae bacteraemia and age ≥65 years, tube insertion and prior use of antibiotics (all P < 0.05). Multivariate analysis showed that prior use of antibiotics (OR = 5.95, 95% CI 1.99–17.79), UTI (OR = 3.46, 95% CI 1.03–11.56) and age ≥65 years (OR = 3.30, 95% CI 1.00–10.89) were independently associated with FQ resistance in communityassociated K. pneumoniae bacteraemia. ESBLs were detected in 25 (62.5%) of the 40 FQ-resistant K. pneumoniae isolates, whilst only 13 (3.5%) of 374 FQ-susceptible K. pneumoniae isolates were ESBLproducers. Although previous studies described the clinical and microbiological epidemiology of FQ-resistant Escherichia coli infections, particularly in the urinary tract, the risk factors for infections with
182
Letters to the Editor / International Journal of Antimicrobial Agents 39 (2012) 177–185
Table 1 Clinical characteristics of community-onset bacteraemias caused by fluoroquinolone (FQ)-resistant and FQ-susceptible Klebsiella pneumoniae.a Characteristic
FQ-resistant (n = 40)
FQ-susceptible (n = 374)
P-value
Age (years) (mean ± S.D.) Old age (≥65 years) Male Healthcare-associated infection ESBL-producing isolates Underlying disease Solid tumour Haematological malignancy Cardiovascular disease Liver disease Renal disease Neurological disease Diabetes mellitus Co-morbid conditions Recent operation within 1 month Immunosuppressant use Neutropenia Corticosteroid use Indwelling urinary catheter Tube insertionb Prior use of antibiotics within 1 month Cephalosporin Fluoroquinolone Site of infection Primary bacteraemia Pneumonia Urinary tract infection Intra-abdominal infection Severe sepsis Pitt bacteraemia score (mean ± S.D.)
61.7 ± 18.0 19 (47.5) 29 (72.5) 24 (60.0)
62.2 ± 14.3 176 (47.1) 226 (60.4) 138 (36.9)
25 (62.5)
13 (3.5)
19 (47.5) 6 (15.0)
148 (39.6) 25 (6.7)
0.331 0.103
9 (22.5) 7 (17.5) 3 (7.5) 7 (17.5) 11 (27.5)
92 (24.6) 90 (24.1) 20 (5.3) 34 (9.1) 91 (24.3)
0.769 0.352 0.477 0.097 0.658
6 (15.0)
18 (4.8)
0.020
7 (17.5) 6 (15.0) 3 (7.5) 5 (12.5) 6 (15.0) 25 (62.5)
55 (14.7) 40 (10.7) 6 (1.6) 18 (4.8) 10 (2.7) 76 (20.3)
0.638 0.425 0.047 0.059 0.002 <0.001
15/34 (44.1) 7/34 (20.6)
43/301 (14.3) 11/292 (3.8)
<0.001 <0.001
9 (22.5) 2 (5.0) 10 (25.0) 15 (37.5) 14/40 (35.0) 1.11 ± 1.98
49 (13.1) 37 (9.9) 52 (13.9) 201 (53.7) 150/371 (40.4) 1.71 ± 2.33
0.104 0.406 0.062 0.051 0.505 0.122
0.815 0.958 0.136 0.004
challenge for clinicians and the current data are especially useful in empirical antimicrobial therapy for community-onset infections. Funding: This study was supported by a Basic Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (No. 20100021572). Competing interests: None declared. Ethical approval: This study was approved by the Institutional Review Board of Samsung Medical Center (Seoul, South Korea).
<0.001
References
S.D., standard deviation; ESBL, extended-spectrum -lactamase. a Data are presented as number (%) of patients, unless otherwise stated. b Nasogastric tube or percutaneous tube.
FQ-resistant pathogens, particularly K. pneumoniae, in the community setting are rarely reported. In this study, we found several variables in healthcare-associated infections that were significantly associated with FQ resistance in community-onset K. pneumoniae bacteraemia. Subgroup analysis of the community-associated K. pneumoniae bacteraemias (excluding healthcare-associated infections) showed that prior use of antibiotics, UTI and age ≥65 years were significantly associated with FQ resistance. These findings suggest that FQ resistance in community-onset K. pneumoniae bacteraemia may be largely associated with the healthcare setting. In this study, 60% of FQ-resistant K. pneumoniae isolates were ESBL-positive compared with 3.5% of FQ-susceptible isolates. This supports a previously observed negative association between FQ susceptibility in E. coli and K. pneumoniae and ESBL production [4,5]. Consistent with those previous studies, we found FQ resistance to be closely related to ESBL-positivity amongst community-onset K. pneumoniae bacteraemias. In conclusion, FQ-resistant K. pneumoniae is a significant cause of community-onset bacteraemia, with relation to healthcareassociated infections. Community-onset FQ-resistant K. pneumoniae bacteraemia was associated with prior use of antibiotics and several other factors associated with healthcare-associated infections. In community-associated infections, prior use of antibiotics, UTI and old age (≥65 years) were independently associated with FQ resistance. Determining the optimal antimicrobial therapy in community-onset K. pneumoniae bacteraemia is now becoming a
[1] Kang CI, Song JH, Chung DR, Peck KR, Ko KS, Yeom JS, et al. Risk factors and pathogenic significance of severe sepsis and septic shock in 2286 patients with Gram-negative bacteremia. J Infect 2011;62:26–33. [2] Lee JA, Kang CI, Joo EJ, Ha YE, Kang SJ, Park SY, et al. Epidemiology and clinical features of community-onset bacteremia caused by extendedspectrum -lactamase-producing Klebsiella pneumoniae. Microb Drug Resist 2011;17:267–73. [3] Friedman ND, Kaye KS, Stout JE, McGarry SA, Trivette SL, Briggs JP, et al. Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 2002;137:791–7. [4] Tolun V, Küc¸ükbasmaci O, Törümküney-Akbulut D, Catal C, An˘g-Küc¸üker M, An˘g O. Relationship between ciprofloxacin resistance and extended-spectrum -lactamase production in Escherichia coli and Klebsiella pneumoniae strains. Clin Microbiol Infect 2004;10:72–5. [5] van der Starre WE, van Nieuwkoop C, Paltansing S, Van’t Wout JW, Groeneveld GH, Becker MJ, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother 2011;66:650–6.
Cheol-In Kang ∗ Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea Jeong-A. Lee a,b Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea b Division of Infectious Diseases, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea a
Yu Mi Wi Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea Doo Ryeon Chung Kyong Ran Peck Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea Nam Yong Lee Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Jae-Hoon Song Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea ∗ Corresponding
author. Tel.: +82 2 3410 0324; fax: +82 2 3410 0064. E-mail addresses: [email protected], [email protected] (C.-I. Kang) 21 June 2011 doi:10.1016/j.ijantimicag.2011.09.025