Factors associated with multidrug-resistant organism (MDRO) mortality: an analysis from the national surveillance of multidrug-resistant organism, 2018-2022 | BMC Infectious Diseases

Factors associated with multidrug-resistant organism (MDRO) mortality: an analysis from the national surveillance of multidrug-resistant organism, 2018-2022 | BMC Infectious Diseases

To our knowledge, this is the largest study in Malaysia that analysed 6 MDROs that were monitored under National MDRO surveillance, which involves 28 hospitals. This study sheds light on the state of Malaysia concerning MDROs.

The mortality outcome among all MDRO-infected patients was 9.6% (n = 951). Our analysis revealed that Gram-negative bacteria (Acinetobacter baumanii, extended-spectrum beta lactamases (ESBL) producing Escherichia coli, extended-spectrum beta lactamases (ESBL) producing Klebsiella pneumoniae, and carbapenem-resistant Entrobacterales (CRE)) were associated with a greater risk of mortality among patients with MDRO infections (p < 0.05). In our study, Acinetobacter baumanii (36.8%, 350) had the highest mortality among MDRO-infected patients. The presence of A. baumannii bacteria is the greatest concern and has been repeatedly highlighted in other studies [19, 22, 23]. Recent research has also indicated that infection with A. baumannii is a contributing factor to mortality in the ICU [17]. The prevalence of commonly isolated MDROs among state hospitals and major specialist hospitals is A. baumannii. Other researchers reported the same findings for their hospital settings [19, 22]. A. baumannii is an opportunistic bacterial pathogen primarily associated with hospital-acquired infections [22]. The lack of adequate infection control measures and overuse of antimicrobial drugs have contributed to the increase in multidrug-resistant A. baumannii [20].

Mortality is significantly greater in healthcare-acquired infections (HCAIs) (p < 0.05) than in non-HCAIs. Studies have shown that MDRO infections are associated with increased mortality in HAIs in which an MDRO is involved (HAI-MDRO), which is 1.7 times greater (HR, 1.7; 95% confidence interval [CI], 1.25–2.32) than in infections caused by susceptible microorganisms [9]. In the National Surveillance of Antibiotic Report of 2022, HCAI had the highest prevalence in state hospitals (5.07%), followed by major specialist hospitals (5.06%) and university hospitals (3.08%) [24]. In healthcare settings, especially critical care, compliance with hand hygiene is crucial to prevent the transmission of infection from healthcare personnel to patients or vice versa. The national surveillance of hand hygiene compliance has improved over the years, with rates ranging from 79.6% in 2016 to 87.2% in 2020. However, the trend of HCAI from 2018 until 2021 has plateaued within the range of 4–5 per 100 admissions [25].

In our study, sterile samples were significantly associated with increased mortality risk (p < 0.05) among MDRO-infected patients, where blood represented 40.8% (n = 4029) of the samples collected and was a sterile specimen. This might be due to bloodstream infections (BSIs), which are commonly found in 40.1% (n = 3960) of MDROs. According to the chi-square analysis, the BSI was significantly associated with MDRO mortality (p < 0.05). According to a report by the Ministry of Health, Malaysia, in the Point Prevalence Survey HCAI findings, BSI was one of the most common types of HCAI [24]. Few studies have revealed that risk factors for mortality in patients with BSI caused by MDROs include an ICU stay, where patients admitted to the intensive care unit (ICU) have a higher risk of mortality due to BSI caused by MDROs [9, 26, 27]. Patients with severe clinical conditions are at increased risk of death [26].

The analysis revealed that MDRO patients who were admitted to medical-based departments had a greater risk of mortality (p < 0.05). This might also be influenced by the fact that, in this study, medical departments and anesthesia departments had a greater number of patients with MDRO infection than did nonmedical-based departments, such as surgical, orthopedic or O&G departments. A previous study revealed that ICU patients had a greater risk of MDRO mortality than surgical wards did [9].

In our study, patients with MDRO infections who were admitted during the post-COVID-19 period (2020–2022) were at lower risk for mortality outcomes than were patients who were admitted before the pandemic (2020–2022) (p < 0.05). However, this is the opposite, as the presence of MDRO infection is strongly associated with increased mortality in individuals with COVID-19. In a recent study, patients with MDRO infections had a fourfold greater risk of death than did those without MDRO infections, where MDRO infections can precipitate the deterioration of patient health, resulting in sepsis and multiple organ failure, ultimately leading to mortality [18].

For the hospital categories, state hospitals had a greater mortality risk than major hospitals did (p < 0.05). One study revealed that the overall in-hospital mortality rate for patients admitted to tertiary care hospitals was greater than that for patients admitted to secondary care hospitals (median in-hospital death rates of 3.7% vs. 2.9%, respectively, p = 0.05) [28]. A study in Brazil revealed that MDRO infection increased hospital mortality [29].

In our study, patients with a history of surgical intervention within the past month and patients who had a history of surgical implantation within 1 year had a lower mortality outcome (p < 0.05). This finding is similar to that of a previous study showing that there was an association between a history of previous surgery and MDRO mortality, and the number of deaths recorded was 13.4% lower (n = 76) in groups with a previous history of surgery than in those with no previous history of surgery (24.4%, n = 106) [9]. However, other studies have consistently shown that patients who have undergone surgery are more likely to develop MDRO infections than are those who have not undergone surgery [14, 15, 17, 30].

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