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A multidrug-resistant microorganism infection risk prediction model: development and validation in an emergency medicine population

  • Juan González del CastilloEmail author
  • Agustín Julián-Jiménez
  • Julio Javier Gamazo-Del Rio
  • Eric Jorge García-Lamberechts
  • Ferrán Llopis-Roca
  • Josep María Guardiola Tey
  • Mikel Martínez-Ortiz de Zarate
  • Carmen Navarro Bustos
  • Pascual Piñera Salmerón
  • Jesús Álvarez-Manzanares
  • María del Mar Ortega Romero
  • Martin Ruiz Grinspan
  • Susana García Gutiérrez
  • Francisco Javier Martín-Sánchez
  • Francisco Javier Candel González
  • on behalf of the INFURG-SEMES investigators (see addedum)
Original Article

Abstract

The aim was to develop a predictive model of infection by multidrug-resistant microorganisms (MDRO). A national, retrospective cohort study was carried out including all patients attended for an infectious disease in 54 Spanish Emergency Departments (ED), in whom a microbiological isolation was available from a culture obtained during their attention in the ED. A MDRO infection prediction model was created in a derivation cohort using backward logistic regression. Those variables significant at p < 0.05 assigned an integer score proportional to the regression coefficient. The model was then internally validated by k-fold cross-validation and in the validation cohort. A total of 5460 patients were included; 1345 (24.6%) were considered to have a MDRO infection. Twelve independent risk factors were identified in the derivation cohort and were combined into an overall score, the ATM (assessment of threat for MDRO) score. The model achieved an area under the curve-receiver operating curve of 0.76 (CI 95% 0.74–0.78) in the derivation cohort and 0.72 (CI 95% 0.70–0.75) in the validation cohort (p = 0.0584). Patients were then split into 6 risk categories and had the following rates of risk: 7% (0–2 points), 16% (3–5 points), 24% (6–9 points), 33% (10–14 points), 47% (15–21 points), and 71% (> 21 points). Findings were similar in the validation cohort. Several patient-specific factors were independently associated with MDRO infection risk. When integrated into a clinical prediction rule, higher risk scores and risk classes were related to an increased risk for MDRO infection. This clinical prediction rule could be used by providers to identify patients at high risk and help to guide antibiotic strategy decisions, while accounting for clinical judgment.

Keywords

MDRO Stewardship Antibiotic resistant Risk factors Empirical antibiotic treatment 

Notes

Acknowledgments

Members of the Infectious Disease Group of The Spanish Emergency Medicine Society (INFURG-SEMES) participating in this study: Beatriz Valle Borrego, Irene Cabrera Rodrigo, Elena Cardona Corrochano, Kristina Kosanic Martín del Campo, Laura Panero Martínez, María Ester Montes Belloso y Sara María Quevedo Soriano (Hospital Universitario Severo Ochoa de Leganés), Ainoa Ugarte Ramos, Cristina Gabara Xanco, Carles Zamora Martínez (Hospital Clinic de Barcelona), Concepción Martínez Muñoz, Elena Fuentes González, Nelva Gallardo Aguilar (Hospital Universitario de Bellvitge), Virginia Álvarez Rodríguez, Ana Herrera Rodríguez, José Luis Montesinos Díaz, Miguel Muñoz Flores, Corina Cazorla Cana, Marta Merlo Loranca, Rodolfo Romero Pareja and Juan Luque Galán (Hospital Universitario de Getafe), Octavio José Salmerón Béliz, Juan Manuel Parra Ramírez, Arancha Escalera Suberviola, Begoña Gonzalo Moreno, José Manuel Mentrida Rodriguez, Silvia Alonso Rodrigo, Camino Fernández del Blanco, Olivia Devora Ruano, Mónica Pozo Peña, José Francisco Valverde Cánovas, Carolina Campelo Gutiérrez (Hospital Universitario Fundación Alcorcón), José Luis García Garmendia, Salomé Taboada Prieto, Vanessa Parra García (Hospital San Juan de Dios del Aljarafe de Bormujos), María Adalid Moll, Marta Arroyo Gallego, Roberto Calvache Arranz, María de las Mercedes Carrasco Sánchez, Francisco Díaz Bonilla, Javier Díaz Luperena, Andrea Victoria Gómez, Alicia Gutiérrez García, Laura Mao Martín, Ana Martín Hermida, Mercedes Mateas Moreno, Catalina Nicoleta Mocanu, Carlos Morante Calvo, María Luisa Pérez Díaz-Guerra, Cristóbal M. Rodríguez Leal and Nahum J. Torres Yebes (Hospital de Universitario del Henares, Coslada), Alberto Pizarro, Carmen del Arco Galán, Andrés von Wernitz Teleki, Natalia Villalba Guijorro, Mónica Negro Rúa, Elvira Contreras Murillo, Mariano Aguilar Mulet, Ana del Rey Ubago, Cristina Santiago Poveda, Raquel Caminero García, Francisco Javier Val de Santos, Sonia González del Val, Marta Caño Hortoneda, Isabel López Isidro, Bárbara Retana Fernández, Laura Cardeñoso Domingo, Mª del Carmen de las Cuevas Torresano, Arturo Manuel Fraile Torres, Laura Llorca Otero, Lydia Chao Ricoy and Íñigo Guerra Molina (Hospital Universitario La Princesa), Miriam Mateo Roca, Sergio Herrera Mateo, Montserrat Seres Roig, Marta Blazquez Andion and Leopoldo Higa Sansone, Ferran Sánchez Reus (Hospital de la Santa Creu i Sant Pau), Eva Quero Motto, Lidia Amador Fajardo, Marta Pérez Valencia, Rocío García Romero, Mónica Belmonte Cerdán, Jesica Martínez Belvis, Miguel Parra Morata, Mabel Coromoto Suárez Pineda, Clara Montesinos Asensio, Ekaitz Valle Rodriguez and Carmen Martínez Toldos (Hospital Universitario de la Arrixaca de Murcia), Ramón Perales (Complejo Hospitalario Universitario de Albacete), Ainhoa Burzaco Sánchez, Idoia Madariga Ordeñana (Hospital Universitario de Basurto), Manel R Chanovas Borràs, Laia Navarro Bargalló, Eric Adrián Mayor Vázquez, Manel Forcadell Arenas and Manuel Martínez Maimó (Hospital Verge de la Cinta de Tortosa), Francisco José Ruiz Ruiz, Nerea Frías Aznar, Sara Lainez Martínez (Hospital Clínico Universitario de Zaragoza), Guillermina Bejarano Redondo, César Carballo, Alejandro Martín Quiros, María Cristina López Paredes, Paloma Isabel Romero Gallego-Acho, Juan Martín Pilares Barco, Rosa Mayayo Alvira, Frank Josué Perdomo García, Ana Catalina Algora Martín, Cristina Marcelo Calvo (Hospital Universitario La Paz), Raúl López Izquierdo, María del Carmen Ramos Sánchez, José Ramón Oliva Ramos, Ainara Portela Martín, Ángela Arévalo Pardal and María Nieves Sobradillo Castrodeza (Hospital Universitario Río Hortega), Raimundo Rodríguez Aguirre, José Gutiérrez Peláez, Mª Soledad Illescas Fernández-Bermejo, Cristina Colmenarejo Serrano (Hospital General Universitario de Ciudad Real), Paula Mostaza Gallar, Mayra Matesanz David, María José Núñez Orantos (Hospital Universitario Clínico San Carlos), Guillermo E. Burillo Putze, María Antonia Miguel Gómez y Carmen Mercedes García Pérez (Hospital Universitario de Canarias de Tenerife), Itziar Huarte Sanz, Ainhoa González Querejeta, Diego Vicente Anza, Tania Martin-Peñaranda (Hospital Universitario Donostia), Agurtzane Auzmendi Aguirre (Hospital de Mendaro), María Arranz Betegón, Cristina Herranz Martínez, Manuel Víctor Duran Ruiz and Ángel Sierra Moreno (Hospital de Viladecans), Leopoldo Sánchez Santos, Silvia Juárez de Sosa and María del Pilar Ortega Lafont (Complejo Asistencial Universitario de Burgos), Miguel Callejas Montoya, Ariel Rubén Lindo Noriega, Gonzalo Fuentes Rodriguez, Ignacio González Molina, Juan Luis Sánchez Rocamora, Leticia Moreillo Vicente, Isaac Mora Escudero, Ana Castillo Morcillo (Hospital de Villarrobledo), Aníbal Blanco Domínguez, María Isabel Antolín Ayala (Hospital de Medina del Campo), Pilar Garrido Espinosa, Alejandro Masie Mebuy, Federico Melgosa Latorre (Hospital Alto Deba), Marta Honrado Fernández de Valderrama, Carmen Gimeno Crepo, Belén Ullibarro Francia (Hospital Santiago Apóstol de Miranda de Ebro), Fernando Rodríguez Pérez-Reverte, María Rocío López Díaz, Sofía Martínez Saldumbide and Leticia Sánchez Martínez, Jesús Cruzado Quevedo (Hospital General Universitario Santa Lucia), Marta Iglesias Vela, Luis Miguel Maestro Gilmartin, Raquel Calleja Fernández, Isabel Fernández Natal, Sonia Gayol Huerga, Mónica Santos Orus (Complejo Asistencial Universitario de León), Félix González Martínez, Diana Moya Olmeda, Primitivo de Paz Varea (Hospital Virgen de La Luz de Cuenca), Jorge García Criado, María Inmaculada García García and Álvaro Muñoz Galindo (Hospital Universitario de Salamanca), Carlos Avellaneda, Fuencisla Hernández, Carmen Peñalver (Complejo Asistencial de Segovia), Javier Oñate (Hospital de Cruces de Barakaldo), María Luisa López Grima, Daniel Castelló García, Isabel Alejandra Subirats Edo (Hospital Universitario Doctor Peset), Manuel Fernández Rodríguez (Hospital San Eloy de Barakaldo-Sestao), Belen Arribas Entrala, José María Ferreras Amez (Hospital Royo Villanova), Rosario Peinado Clemens, Miguel Fajardo Olivares (Hospital Universitario de Badajoz), Blas Giménez Fernández (Hospital Universitario del Vinalopó), Mª Ángeles Leciñena Esteban, Anabel Berzosa Ortega, Hatim Bennouna Slaoui, Juan Diego Isidoro Palmerin (Hospital Can Misses), Manuel Salido Mota (Hospital Universitario Regional de Málaga), Francisco José Ezponda Inchauspe, Ana María Iturzaeta Gorrotxategi (Hospital de Zumárraga), Gema Muñoz Gamito (Hospital Universitari Mutua Terrassa), Sílvia Flores Quesada, Osvaldo Troiano Ungerer (Hospital Santa Tecla de Tarragona), Ainhoa Urraca, María Fe Brezmez, Itziar González Mendía, David Diego Pinto (Complejo Asistencial de Zamora), Begoña Mora Ordóñez, Ana María Comino García (Hospital Virgen de la Victoria de Málaga), Rigoberto del Río Navarro (Hospital Universitario de Torrevieja), Sergio Navarro (Hospital Universitario de La Ribera), Elena Carrasco Fernández (Hospital de Altagracia de Manzanares), Ángel Macías, María Teresa Hernandez Jiménez (Complejo Asistencial de Ávila), Sara Gayoso Martín (Hospital El Escorial), Ángel Estella García (Hospital de Jerez), Elena Martínez Cánovas, Sergio Pastor Marín, Gaélica Bornás Cayuela, Alba Hernández Sánchez, José Andrés Sánchez Nicolás (Hospital Universitario Reina Sofia de Murcia), Maria Deban Fernandez (Hospital Universitario Central de Asturias), Isabel Morales Barroso, José Gallardo Bautista, and Fernando Oltra Hostalet (Hospital Universitario Virgen Macarena).

Author contributions

All authors contributed to the development of the study protocol. JGC and AJJ planned the study concept and design. JGC obtained ethics committee approval and supervised the study. The other authors and members of the Infectious Disease Group of the Spanish Emergency Medicine Society collected all the data. AJJ and JGC analysed and interpreted the data. SGG provided statistical advice. AJJ and JGC prepared the first draft of the manuscript. All authors contributed to manuscript revision and all approved the final document.

Funding information

This study received no financial support. The promoter of this study was the Infectious Disease Group of the Spanish Emergency Medicine Society. This group received financial support from Merck, Tedec-Meiji, Thermo Fisher, ViroGates and GSK in the last year to organise conferences and group meetings. None of the authors has received any financial compensation.

Compliance with ethical standards

Competing interests

The authors declare that they have no conflicts of interest.

Ethics approval

The Ethical Committee of the Clínico San Carlos Hospital approved the study, as well as by the ethics board of each hospital where necessary. All patients were enrolled in accordance with the Helsinki declaration.

Consent for publication

No individual participant data is reported that would require consent to publish from the participant (or legal parent or guardian for children).

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Juan González del Castillo
    • 1
    • 2
    Email author
  • Agustín Julián-Jiménez
    • 3
  • Julio Javier Gamazo-Del Rio
    • 4
  • Eric Jorge García-Lamberechts
    • 1
    • 2
  • Ferrán Llopis-Roca
    • 5
  • Josep María Guardiola Tey
    • 6
  • Mikel Martínez-Ortiz de Zarate
    • 7
  • Carmen Navarro Bustos
    • 8
  • Pascual Piñera Salmerón
    • 9
  • Jesús Álvarez-Manzanares
    • 10
  • María del Mar Ortega Romero
    • 11
  • Martin Ruiz Grinspan
    • 12
  • Susana García Gutiérrez
    • 13
  • Francisco Javier Martín-Sánchez
    • 1
    • 2
  • Francisco Javier Candel González
    • 2
    • 14
  • on behalf of the INFURG-SEMES investigators (see addedum)
  1. 1.Emergency DepartmentHospital Universitario Clínico San CarlosMadridSpain
  2. 2.Health Research Institute (IdISSC)Hospital Universitario San CarlosMadridSpain
  3. 3.Emergency DepartmentComplejo Hospitalario Universitario de Toledo, Universidad de Castilla La ManchaToledoSpain
  4. 4.Emergency DepartmentHospital Universitario de Galdakao-UsansoloBizkaiaSpain
  5. 5.Emergency DepartmentHospital Universitario de BellvitgeBarcelonaSpain
  6. 6.Emergency DepartmentHospital Universitario Sant Pau. Universidad Autónoma de Barcelona. Universidad Internacional de CatalunyaBarcelonaSpain
  7. 7.Emergency DepartmentHospital Universitario de BasurtoBilbaoSpain
  8. 8.Emergency DepartmentHospital Universitario Virgen de la MacarenaSevillaSpain
  9. 9.Emergency DepartmentHospital Universitario Reina SofíaMurciaSpain
  10. 10.Emergency DepartmentHospital Universitario Rio HortegaValladolidSpain
  11. 11.Emergency DepartmentHospital ClínicBarcelonaSpain
  12. 12.Emergency DepartmentHospital Universitario del HenaresMadridSpain
  13. 13.Research Unit. REDISSECHospital de Galdakao-UsansoloBizkaiaSpain
  14. 14.Clinical Microbiology DepartmentHospital Universitario Clínico San CarlosMadridSpain

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