Piperacillin

The CLABSIs,⁷ CAUTIs,⁸ select VAEs,⁹ and SSIs¹⁰ that occurred between 2015–2017 and had been reported to the NHSN’s Patient Safety Component as of July 1, 2018, were included in this report. These HAIs were reported by acute-care hospitals, critical access hospitals, LTACHs, and IRFs from all US states and territories. Unless otherwise noted, CLABSI data included events classified as mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI). VAE data were limited to events classified as possible ventilator-associated pneumonia (PVAP) because this is the only subtype of VAE for which a pathogen can be reported. Asymptomatic bacteremic urinary tract infections, CLABSIs reported from IRFs, and outpatient SSIs were excluded.
The NHSN protocols provide guidance for attributing device-associated (DA) HAIs (ie, CLABSIs, CAUTIs, and PVAPs) to a CDC-defined location type, and SSIs to a CDC operative procedure code. Due to known differences in pathogens and resistance patterns between adult and pediatric populations,^{11 ,12 (link)} this report was limited to DA HAIs attributed to adult location types, and to SSIs that occurred in patients ≥18 years old at the time of surgery. Comparable data from pediatric locations and patients are described in a companion report.^{13 (link)}Unless otherwise noted, DA HAIs were stratified into 5 mutually exclusive location categories: hospital wards (inclusive of step-down, mixed acuity, and specialty care areas), hospital intensive care units (ICUs), hospital oncology units (ie, oncology ICUs and wards), LTACHs (ie, LTACH ICUs and wards), and IRFs (ie, freestanding IRFs and CMS-certified IRF units located within a hospital). SSI data were stratified into mutually exclusive surgical categories based on the operative procedure code. Pathogen distributions were also analyzed separately for each operative procedure code and are available in the online supplement.¹⁴ Up to 3 pathogens and their antimicrobial susceptibility testing (AST) results can be reported to the NHSN for each HAI. The AST results for the drugs included in this analysis were reported using the interpretive categories of “susceptible” (S), “intermediate” (I), “resistant” (R), or “not tested.” Instead of “intermediate,” cefepime had the category interpretation of “intermediate/susceptible-dose dependent” (I/S-DD), which was treated as I for this analysis. Laboratories are expected to follow current guidelines from the Clinical and Laboratory Standards Institute (CLSI) for AST.¹⁵ Naming conventions for pathogens generally adhered to the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) Preferred Term.¹⁶ In some cases, pathogens were grouped by genus or clinically recognized group (eg, viridans group streptococci) (Appendices A2–A4 online). Results for Klebsiella spp were limited to K. pneumoniae and K. oxytoca; K. aerogenes was considered part of Enterobacter spp due to the timing of the NHSN’s adoption of its name change.^{17 (link)}Staphylococcus aureus was defined as methicillin-resistant (MRSA) if the isolate was reported as R to oxacillin, cefoxitin, or methicillin. Enterococcus spp isolates were defined as vancomycin-resistant (VRE) if they tested R to vancomycin. VRE data were analyzed for all HAIs except PVAP because Enterococcus spp are excluded from the NHSN’s PVAP surveillance definition under most scenarios. Carbapenem-resistant Enterobacteriaceae (CRE) were defined as Klebsiella spp, Escherichia coli, or Enterobacter spp that tested R to imipenem, meropenem, doripenem, or ertapenem. All other pathogen-antimicrobial combinations (phenotypes) were described using a metric for nonsusceptibility, which included pathogens that tested I or R to the applicable drugs. To be defined as nonsusceptible to extended-spectrum cephalosporins (ESCs), pathogens must have tested I or R to either ceftazidime or cefepime (Pseudomonas aeruginosa) or to ceftazidime, cefepime, ceftriaxone, or cefotaxime (Klebsiella spp and E. coli). For Enterobacter spp, evaluation of nonsusceptibility to ESCs was limited to cefepime due to Enterobacter’s inducible resistance to other ESCs. Fluoroquinolone nonsusceptibility was defined as a result of I or R to either ciprofloxacin or levofloxacin (P. aeruginosa) or to ciprofloxacin, levofloxacin, or moxifloxacin (E. coli). Carbapenem nonsusceptibility in P. aeruginosa and Acinetobacter spp was defined as a result of I or R to imipenem, meropenem, or doripenem. Nonsusceptibility to aminoglycosides was defined as a result of I or R to gentamicin, amikacin, or tobramycin. Finally, multi-drug-resistance (MDR) was approximated by adapting previously established definitions^{18 (link)} that require nonsusceptibility to at least 1 agent within 3 different drug classes. For Enterobacteriaceae and P. aeruginosa, 5 classes were considered in the criteria: ESCs (or cefepime for Enterobacter spp), fluoroquinolones, aminoglycosides, carbapenems, and piperacillin (PIP) or piperacillin/tazobactam (PIPTAZ). A sixth class, ampicillin/sulbactam, was included in the criteria for Acinetobacter spp.
Data were analyzed using SAS version 9.4 software (SAS Institute, Cary, NC). For all HAIs and pathogens, absolute frequencies and distributions were calculated by HAI, location, and surgical category. The 15 most commonly reported pathogens were identified, and their frequencies and ranks within each stratum were calculated. A pooled mean percentage nonsusceptible (%NS) was calculated for each phenotype as the sum of nonsusceptible (or resistant) pathogens, divided by the sum of pathogens tested for susceptibility, and multiplied by 100. Percentage NS was not calculated for any phenotype for which <20 pathogens were tested. Differences in the %NS across location types or surgical categories were assessed for statistical significance using a mid-P exact test, and P < .05 was considered statistically significant. The percentage of pathogens with reported susceptibility results (referred to as “percentage tested”) is defined elsewhere^{3 (link)} and was calculated for each bacterial phenotype, as well as for select Candida spp. Pathogens and susceptibility data for CLABSIs categorized as MBI-LCBI were analyzed separately and are presented in the online supplement.¹⁴ “Selective reporting” occurs when laboratories suppress AST results as part of antimicrobial stewardship efforts. This practice could contribute to a higher number of pathogens reported to the NHSN as “not tested” to certain drugs. To assess the impact of selective reporting on the national %NS, we applied an alternate calculation for CRE and ESC nonsusceptibility. If a pathogen was reported as “not tested” to carbapenems, susceptibility was inferred as S if the pathogen tested susceptible to at least 2 of the following: ampicillin, ampicillin/sulbactam, amoxicillin/clavulanic acid, PIPTAZ, cefazolin, cefoxitin, or cefotetan. If a pathogen was reported as “not tested” to ESCs, susceptibility was inferred as S if the pathogen tested susceptible to at least 2 of the following: ampicillin, aztreonam, or cefazolin. Therefore, the number of tested isolates increases under the alternate calculation. Percentage NS was calculated using both the traditional (ie, strictly as reported) and alternate approaches.
Statistical analyses were not performed to test for temporal changes in the %NS; thus, this report does not convey any conclusions regarding changes in resistance over time. Due to differences in the stratification levels, inclusion criteria, and patient populations, the %NS values in this report should not be compared to those published in previous iterations of this report.