title: A multinational survey of risk factors for infection with extended-spectrum beta-lactamase-producing enterobacteriaceae in nonhospitalized patients.
abstract: BACKGROUND
  Infections caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are increasing in frequency and are associated with high mortality rates. Circulation of CTX-M-type ESBLs in the community is of particular concern, because it may confound standard infection-control measures.
  
  
  METHODS
  We analyzed the results of epidemiologic studies of infection caused by ESBL-producing Enterobacteriaceae in nonhospitalized patients from 6 centers in Europe, Asia, and North America. Risk factors for infection with an ESBL-producing organism were identified by univariate and multivariate analyses.
  
  
  RESULTS
  A total of 983 patient-specific isolates were reviewed (890 [90.5%] of which were Escherichia coli, 68 [6.9%] of which were Klebsiella species, and 25 [2.5%] of which were Proteus mirabilis); 339 [34.5%] of the isolates produced ESBLs. CTX-M types were the most frequent ESBLs (accounting for 65%). Rates of co-resistance to ciprofloxacin among ESBL-producing isolates were high (>70%), but significant variation was seen among centers with respect to rates of resistance to gentamicin, amoxicillin-clavulanate, and trimethoprim-sulfamethoxazole. Similar risk factors for infection with an ESBL-producing organism were found in the different participating centers. Significant risk factors, identified by multivariate analysis, were recent antibiotic use, residence in a long-term care facility, recent hospitalization, age 65 years, and male sex (area under the receiver-operator characteristic [ROC] curve, 0.80). However, 34% of ESBL-producing isolates (115 of 336 isolates) were obtained from patients with no recent health care contact; the area under the ROC curve for the multivariate model for this group of patients was only 0.70, which indicated poorer predictive value.
  
  
  CONCLUSIONS
  Community-acquired ESBL-producing Enterobacteriaceae are now prevalent worldwide, necessitating international collaboration. Novel approaches are required to adequately address issues such as empirical treatment for severe community-acquired infection and infection control.
authors.affiliation: Infectious Diseases Unit and the 2Division of Epidemiology, Tel Aviv Medical Center, Tel Aviv, Israel. rbenami@mdanderson.org <rbenami@mdanderson.org>
authors.forename: Ronen
authors.initials: R
authors.lastname: Ben-Ami
authors.forename: Jesús
authors.initials: J
authors.lastname: Rodríguez-Baño
authors.forename: Hande
authors.initials: H
authors.lastname: Arslan
authors.forename: Johann D D
authors.initials: JD
authors.lastname: Pitout
authors.forename: Claudine
authors.initials: C
authors.lastname: Quentin
authors.forename: Esther S
authors.initials: ES
authors.lastname: Calbo
authors.forename: Ozlem K
authors.initials: OK
authors.lastname: Azap
authors.forename: Corinne
authors.initials: C
authors.lastname: Arpin
authors.forename: Alvaro
authors.initials: A
authors.lastname: Pascual
authors.forename: David M
authors.initials: DM
authors.lastname: Livermore
authors.forename: Javier
authors.initials: J
authors.lastname: Garau
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Carmeli
mesh_terms: D017714:Community-Acquired Infections / Q000453:epidemiology / Q000382:microbiology; D004755:Enterobacteriaceae / Q000187:drug effects / Q000201:enzymology*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D014943:Global Health; D006306:Health Surveys; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D015999:Multivariate Analysis; D015995:Prevalence; D012372:ROC Curve; D012307:Risk Factors; D018440:beta-Lactam Resistance; D001618:beta-Lactamases / Q000096:biosynthesis* / Q000235:genetics
chemical_list: D001618:beta-Lactamases