Risk factors and clinical significance of ertapenem-resistant Klebsiella pneumoniae in hospitalised patients

Ertapenem-resistant Klebsiella pneumoniae (ER-Kp) is an emerging healthcare-associated pathogen. In order to identify risk factors associated with ER-Kp acquisition, the records of 100 patients from whom K. pneumoniae had been isolated between July 2008 and December 2009 were reviewed. These comprised 38 with ER-Kp (28 infected, 10 colonised) and 62 with ertapenem-susceptible K. pneumoniae (ES-Kp) (43 infected, 19 colonised). Multilocus sequence typing (MSLT) and porin gene investigation performed on 25 ER-Kp strains showed that 24 belonged to the ST37 lineage, expressing a novel OmpK36 variant and not expressing OmpK35. Breakthrough bacteraemia occurred in 13 (52%) of 25 bloodstream infections (BSIs). Among nine ER-Kp BSIs, five were complicated by breakthrough bacteraemia, of which four developed during carbapenem therapy. Among 16 ES-Kp BSIs, breakthrough bacteraemia developed in eight patients (50%), but only one occurred (12%) during carbapenem therapy. Logistic regression analysis showed that carbapenems (odds ratio: 12.9; 95% confidence interval: 3.09-53.7; P<0.001), second generation cephalosporins (11.8; 1.87-74.4; P<0.01), endoscopy (5.59; 1.32-23.6; P<0.02), acute renal failure (5.32; 1.13-25.1; P= 0.034) and third generation cephalosporins (4.15; 1.09-15.8; P<0.01) were independent risk factors for acquisition of ER-Kp. Our findings confirm that prior use of certain antimicrobials, specifically carbapenems and cephalosporins, are primary independent risk factors for colonisation or infection with ER-Kp.