Risk factors and outcomes for children with carbapenem-resistant Enterobacteriaceae: a multicenter case series

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly identified causes of healthcare-associated infections in adults, but little is known about CRE in children.

Methods: Patients <21 years admitted to The ChildrenÕs Hospital of Philadelphia, JohnÕs Hopkins Hospital, or Boston ChildrenÕs Hospital with CRE isolated from clinical cultures between 2011 and 2015 were included. Data were obtained by medical record review and analyzed using descriptive statistics.

Results: Sixty-two unique patients with CRE were identified. Enterobacter species were isolated most often, followed by Klebsiella species. Approximately half of isolates were tested for carbapenemase production and 61% were positive (Figure 1). Patient characteristics are shown in Table 1. Prior hospitalization (n=31; 50%) and medical care abroad (n=10; 16%) were common. Rates of recent broad-spectrum antibiotic use, including carbapenems (n=23; 37%), were high. Combination therapy was prescribed infrequently and 60-day mortality was 11% (Table 2).

Conclusion: Our study identifies several important risk factors for CRE in children and highlights key differences from adult patients, including a predominance of Enterobacter species, infrequent use of dual therapy, and substantially lower mortality.

Figure 1. Microbiology (n=62)

a. Organism

b. Source

 

c. Carbapenemase testing

Table 1. Baseline clinical and demographic variables

Variable	n=62
Median age, months (IQR)	24 (5, 144)
Male	44 (71)
Recent acute care admission	31 (50)
Median LOS, days (IQR)	41 (16, 85)
Transfer from outside facility	15 (24)
Long-term care facility resident	3 (5)
International healthcare	10 (16)
United Arab Emirates	3 (30)
India	1 (10)
Kuwait	4 (40)
Pakistan	1 (10)
Saudi Arabia	1 (10)
ICU admission	37 (60)
Comorbidities
Hematopoietic stem cell transplant	1 (2)
Solid organ transplant	7 (11)
Malignancy	8 (13)
Congenital heart disease	6 (10)
Prematurity	11 (18)
Renal/urologic	13 (21)
Devices
Central line	38 (61)
Tracheostomy	9 (15)
Endotracheal tube	20 (32)
Urinary Catheter	11 (18)
Recent surgery	40 (65)
Anti-pseudomonal exposure	44 (71)
Carbapenem exposure	23 (37)

Table 2. Treatment and outcomes for patients with CRE infection

Variable	n=27
Combination antibiotic therapy	5 (19)
60-day attributable mortality	3 (11)
Recurrent Infection	5 (19)