Multidrug-resistant gram-negative organisms and setting of onset in persons with spinal cord injury and disorder

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A Northwestern University Capstone Project

Abstract

Background: The number of infections caused by multidrug-resistant gram-negative organisms (MDRGNOs) continues to rise. Individuals with spinal cord injury or disorder (SCI/D) are at an increased risk of infections due to high healthcare utilization and prevalence of comorbidities. While a relationship between MDRGNOs and the SCI/D population had been established, the epidemiologic location of onset had not yet been studied. The goal of this study was to classify and compare characteristics and outcomes related to the epidemiologic location of onset, including hospital-acquired, healthcare-associated, and community acquired infections of MDRGNOs in veterans with SCI/D.Methods: A 2-year retrospective cohort study was done of 19,567 patients with SCI/D who received care at a VA facility from 2012-2013. Cultures that were positive for urinary tract, bloodstream, or respiratory infections and received antibiotic use 7 days were included in the analysis. A total of 2,547 hospital-acquired, 1,989 healthcare-associated, and 1,209 community onset MDRGNO cultures were included in the analysis from 2,607 participants. Bivariate and multivariable, multinomial logistic regression were used to compare the three onset groups with a significance level of p<0.0167 due to multiple comparisons.Results: Compared to the hospital-acquired onset group, healthcare-associated infections had significantly reduced odds of several medical characteristics and comorbidities with pressure ulcers producing the lowest odds of healthcare-associated infection (OR=0.13, 95% CI 0.11-0.15, p<0.0001). Hospital-acquired infections compared to community-acquired onset resulted in over a 3-fold greater event frequency for long-term care stay, mechanical ventilation, and surgery (OR=4.53, 95% CI 2.76-7.42, p<0.0001, OR=3.53, 95% CI 2.34-5.33, p<0.0001, and OR=3.34, 95% CI 2.47-4.51, p<0.0001, respectively). Escherichia coli was identified as a causative agent in 52.9% of community-acquired cultures and was found significantly more often in community acquired infections than in hospital-acquired infections (p<0.0001). An increased odds of mortality was associated with hospital-acquired infections compared to the community-acquired group for both 90-day and 1-year mortality (OR=2.11, 95% CI 1.41, 3.15, p=0.0003 and OR=2.37, 95% CI1.79-3.14, p<0.0001), and healthcare-associated infections were associated with reduced odds of 30-day, 90-day, and 1-year mortality compared to hospital-acquired infections.Conclusion: Hospital-acquired, healthcare-associated, and community-acquired infections vary by many demographic and medical characteristics, concurrent comorbidities, and causative organisms. Healthcare providers should stay cognizant of the frequency of MDRGNOs when treating individuals with SCI/D due to the high prevalence. Targeted therapies and preventionstrategies may be necessary to combat the escalating burden MDRGNOs have on providers, patients, and the entire healthcare system.

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