Carbapenem-resistant Enterobacterales sepsis following endoscopic retrograde cholangiopancreatography: risk factors for 30-day all-cause mortality and the development of a nomogram based on a retrospective cohort

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) has become a routine endoscopic procedure that is essential for diagnosing and managing various conditions, including gallstone extraction and the treatment of bile duct and pancreatic tumors. Despite its efficacy, post-ERCP infections - particularly those caused by carbapenem-resistant Enterobacterales (CRE) - present significant risks. These risks highlight the need for accurate predictive models to enhance postprocedural care, reduce the mortality risk associated with post-ERCP CRE sepsis, and improve patient outcomes in the context of increasing antibiotic resistance.

Objective: This study aimed to examine the risk factors for 30-day mortality in patients with CRE sepsis following ERCP and to develop a nomogram for accurately predicting 30-day mortality risk.

Methods: Data from 195 patients who experienced post-ERCP CRE sepsis between January 2010 and December 2022 were analyzed. Variable selection was optimized via the least absolute shrinkage and selection operator (LASSO) regression model. Multivariate logistic regression analysis was then employed to develop a predictive model, which was evaluated in terms of discrimination, calibration, and clinical utility. Internal validation was achieved through bootstrapping.

Results: The nomogram included the following predictors: age > 80 years (hazard ratio [HR] 2.61), intensive care unit (ICU) admission within 90 days prior to ERCP (HR 2.64), hypoproteinemia (HR 4.55), quick Pitt bacteremia score ≥ 2 (HR 2.61), post-ERCP pancreatitis (HR 2.52), inappropriate empirical therapy (HR 3.48), delayed definitive therapy (HR 2.64), and short treatment duration (< 10 days) (HR 5.03). The model demonstrated strong discrimination and calibration.

Conclusions: This study identified significant risk factors associated with 30-day mortality in patients with post-ERCP CRE sepsis and developed a nomogram to accurately predict this risk. This tool enables healthcare practitioners to provide personalized risk assessments and promptly administer appropriate therapies against CRE, thereby reducing mortality rates.

Keywords: Carbapenem-resistant Enterobacterales; Endoscopic retrograde cholangiopancreatography; Mortality; Nomogram; Sepsis.

Fig. 1

Flowchart delineating the inclusion of patients with CRE sepsis following ERCP. Abbreviations: ERCP, Endoscopic retrograde cholangiopancreatography; CRE, Carbapenem-resistant Enterobacterales

Fig. 2

LASSO regression variable selection. (A) The variation attributes of the variable coefficients; (B) the selection procedure for the optimal value of the parameter λ within the LASSO regression model

Fig. 3

Estimating the likelihood of 30-day mortality in patients with CRE sepsis post-ERCP: a model utilizing nomogram predictions. Abbreviations: ERCP, Endoscopic retrograde cholangiopancreatography; CRE, Carbapenem-resistant Enterobacterales

Fig. 4

Assessment and verification of the nomogram. (A) ROC curve representation of the nomogram, SOFA score, and LODS score in the training set and (B) internal validation set. (C) Construction of calibration curves in the training set. (D) DCA curve depicting medical intervention efficacy in patients as evaluated by the nomogram, SOFA score, and LODS. (E) Kaplan‒Meier survival curves for patients with CRE sepsis post-ERCP grouped according to the nomogram. The p value (< 0.001) was ascertained via the log-rank test. The information within the table shows the number at risk at particular time instances. Abbreviations: Sequential Organ Failure Assessment score (SOFA), Logistic Organ Dysfunction Score (LODS)

Fig. 5

Visual representation of the consequences of different antimicrobial therapies shown through Kaplan‒Meier curves. (A) There was no difference in 30-day mortality among patients who were given empirical carbapenems. (B-C) Patients who received empirical tigecycline had a negative prognosis within 30 days, whereas those who received empirical polymyxin B had a survival benefit within the same time frame. (D) There was no variation in the 30-day mortality rate among patients who received combination therapy with carbapenem. (E) Individuals who received combination therapy involving tigecycline experienced an unfavorable prognosis within a 30-day period. (F) On the other hand, individuals who received combination therapy involving polymyxin B experienced a survival advantage for a period of 30 days