Burden of multidrug and extensively drug-resistant ESKAPEE pathogens in a secondary hospital care setting in Greece

Abstract

Bacterial antibiotic resistance (AMR) is a significant threat to public health, with the sentinel 'ESKAPEE' pathogens, being of particular concern. A cohort study spanning 5.5 years (2016-2021) was conducted at a provincial general hospital in Crete, Greece, to describe the epidemiology of ESKAPEE-associated bacteraemia regarding levels of AMR and their impact on patient outcomes. In total, 239 bloodstream isolates were examined from 226 patients (0.7% of 32 996 admissions) with a median age of 75 years, 28% of whom had severe comorbidity and 46% with prior stay in ICU. Multidrug resistance (MDR) was lowest for Pseudomonas aeruginosa (30%) and Escherichia coli (33%), and highest among Acinetobacter baumannii (97%); the latter included 8 (22%) with extensive drug-resistance (XDR), half of which were resistant to all antibiotics tested. MDR bacteraemia was more likely to be healthcare-associated than community-onset (RR 1.67, 95% CI 1.04-2.65). Inpatient mortality was 22%, 35% and 63% for non-MDR, MDR and XDR episodes, respectively (P = 0.004). Competing risks survival analysis revealed increasing mortality linked to longer hospitalisation with increasing AMR levels, as well as differential pathogen-specific effects. A. baumannii bacteraemia was the most fatal (14-day death hazard ratio 3.39, 95% CI 1.74-6.63). Differences in microbiology, AMR profile and associated mortality compared to national and international data emphasise the importance of similar investigations of local epidemiology.

Keywords: ESKAPE; hospital epidemiology; microbial drug resistance; mortality; secondary care; survival analysis.

Fig. 1.

Resistance levels of ESKAPEE bloodstream isolates (n = 235). Four isolates were excluded as full antibiogram data were missing (one A. baumannii, two E. coli and one K. pneumoniae).

Fig. 2.

Cumulative incidence functions for in-hospital mortality (on the left) and discharge alive (on the right) by antimicrobial resistance level (upper panel) and ESKAPEE organism (lower panel) isolated from blood in 226 patients. Lower incidence of hospital discharge alive indicates longer hospitalisation after bacteraemia onset. MDR, multidrug resistant; XDR extensively drug resistant.