| Objective The emergence and spread of Carbapenem-resistant Enterobacteriaceae(CRE)are serious threats to public health worldwide.Patients with hematological diseases are at high risk of CRE intestinal colonization,clinical research of CRE intestinal colonization and CRE bloodstream infection with initially CRE intestinal colonization in hematological diseases is scarce,In this study,we tried to analyze the risk factors of CRE intestinal colonization of hematological diseases,summarize the clinical characteristics of CRE bloodstream infection initially colonized with CRE in the intestinal tract,and compare the antimicrobial resistance of the strains isolated from stool and blood.Methods This study retrospectively collected clinical data of patients with hematological diseases who were hospitalized in the Hangzhou First People’s Hospital and detect stool samples for CRE from March 2017 to March 2019.Patients with CRE intestinal colonization were recruited as case group,the patients with non-CRE intestinal colonization whose age difference was 2 years with the ratio 1:1 of each matched case were recruited as a control group,the clinical variables of CRE intestinal colonization group and non-CRE intestinal colonization group were compared,such as the stage of hematological diseases(newly diagnosed,complete remission,refractory and relapsed),ECOG score,neutropenia,gastrointestinal symptoms,the length of hospital stay,repeated hospitalizations,chemotherapy,antibiotic exposure within 3 months,Logistic regression was used to identify the independent risk factors of CRE intestinal colonization in patients with hematological diseases.Meanwhile,the clinical characteristics of bloodstream infection with initially CRE colonized in the intestinal tract were analyzed retrospectively,and the antimicrobial resistance of CRE strains isolated from stool and blood were compared.All statistical analyses were performed with the SPSS 25.0 software,Results1.The detection rate of intestinal CRE in patients with hematological diseases was 10.2%,Klebsiella pneumoniae accounted for 73.3%,Escherichia coli for 7.9%,Klebsiella oxytoca for 6.9%,Enterobacter aerogenes for 5.9%,Enterobacter cloacae for 5.0%,Citrobacter freundii for 1.0%..2.Comparing the clinical variables of 47 patients with CRE intestinal colonization and 47 patients with non-CRE intestinal colonization,the univariate analysis showed the stage of relapsed and refractory,ECOG score 4,days with neutropenia,gastrointestinal symptoms,the length of hospital stay,repeated hospitalizations,chemotherapy,CSE infection history,bloodstream infection history(excluding CRE),antibiotic exposure within 3 months(penicillin,carbapenem,tigecycline,teicoplanin,and linezolid)accounted for higher proportion in the CRE intestinal colonization group than non-CRE intestinal colonization group(P<0.05).Logistic regression multivariate analysis showed the stage of relapsed and refractory(OR=11.195,95%CI 1.596～78.514,P=0.015),penicillin exposure within 3 months(OR=4.162,95%CI 1.147～15.098,P=0.030),carbapenem exposure within 3 months(OR=23.096,95%CI 6.623～80.538,P=0.000)were independent risk factors for CRE intestinal colonization in patients with hematological diseases.3.Five patients(10.6%)with hematological disease developed CRE bloodstream infection with initially CRE intestinal colonization,and the strains isolated from stool and blood were all Carbapenem-resistant Klebsiella pnezmoniae,four patients(80%)died because of CRKP blood infection within 30 days of CRKP infection onset.All CRKP bloodstream infection cases were in persistent CRKP intestinal colonization accounting for 29.4%of all 17 patients with persistent CRKP intestinal colonization,and all cases were in febrile neutropenia with gastrointestinal symptoms.4 patients were in continued febrile neutropenia from CRKP infection onset to death,while one patient was cured by antibiotic treatment and recovered from febrile neutropenia.The median time was 6.5d from blood sample collection to death of the 4 died.4.Compared with antimicrobial resistance of CRKP strains isolated from the stool and blood,both CRKP strains were all resistant to penicillin,cephalosporin,quinolones,aminoglycoside,and carbapenem.One CRKP strain(20%)isolated from blood showed resistance to tigecycline,other strains isolated from stool or blood were sensitive to tigecycline,CRKP strains isolated from stool and blood showed high coherence.Five patients all received initial antimicrobial treatment from CRKP infection onset,three patients received adequate initial antimicrobial treatment and two of them died attribute to CRKP bloodstream infection,two patients received inadequate initial antimicrobial treatment and all of them died of CRKP bloodstream infection.Conclusion1.Carbapenem-resistant Klebsiella pneumoniae was the most common CRE colonized in the intestinal tract in patients with hematological diseases.2.the stage of relapsed and refractory,penicillin exposure within 3 months,carbapenem exposure within 3 months were independent risk factors for CRE intestinal colonization in patients with hematological diseases.3.CRKP was the most common pathogen in CRE bloodstream infection with high mortality.Patients with hematological diseases in persistent CRKP intestinal colonization developed CRKP bloodstream infection in a high proportion,febrile neutropenia and gastrointestinal symptoms are the most common clinical manifestations for CRKP bloodstream infection.In patients with hematological diseases developed for CRKP bloodstream infection,the mortality rate is extremely high when they continue to suffer from febrile neutropenia.4.the mortality rate is high when patients with hematological diseases in CRKP bloodstream infection received inadequate initial antimicrobial treatment,the time from onset of CRKP bloodstream infection to death is short,adequate initial antimicrobial treatment therapy can be implemented according to the antimicrobial sensitivity and resistance of CRKP colonized in the intestinal tract,and tigecycline could be used as an effective treatment for CRKP bloodstream infection. |
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