title: Simple bedside score to optimize the time and the decision to initiate appropriate therapy for carbapenem-resistant Enterobacteriaceae.
abstract: BACKGROUND
  Epidemiological characteristics of patients with bloodstream infections (BSI) due to extended-spectrum β-lactamase producing (ESBL) and carbapenem-resistant (CRE) strains are often similar. Mortality rates for CRE BSI are 70%, and mean time to initiation of appropriate therapy is ~5 days. A bedside score was developed to differentiate CRE-BSIs from ESBL-BSIs, in order to help decrease the time to initiation of appropriate therapy for CRE and mortality rates.
  
  
  RESULTS
  Score was developed based of data (2007-2010) abstracted from charts of adult patients from Assaf Harofeh Medical Center (AHMC, Zeriffin, Israel), and validated on a cohort of patients from Detroit Medical Center (DMC, MI, USA). A multivariate model for presence of CRE was generated. A clinical prediction score and ROC curve was derived. 451 patients with ESBL BSIs (285 from AHMC and 166 from DMC) and 74 patients with CRE BSIs (58 from AHMC and 16 from DMC) were included. The prediction score included chemotherapy in the past 3 months (19 points), presence of foreign invasive devices (10 points), no peripheral vascular disease (10 points), reduced consciousness or cognition at time of acute illness (9 points), time in hospital prior to BSI ≥ 3 days (7 points), and age younger than 65 years (6 points). A score of ≥32 to define "high CRE risk" had sensitivity of 59%, specificity of 76%, PPV of 34% and NPV of 90%.
  
  
  CONCLUSIONS
  The score's 90% NPV implies it could reduce un-necessary (and toxic) empiric use of anti-CRE therapeutics, but this should be studied prospectively and on broader populations in order to test its potential role in reducing mortality.
authors.affiliation: Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Violet
authors.initials: V
authors.lastname: Leibman
authors.affiliation: Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.
authors.forename: Emily T
authors.initials: ET
authors.lastname: Martin
authors.affiliation: Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Ruthy
authors.initials: R
authors.lastname: Tal-Jasper
authors.affiliation: Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
authors.forename: Leonti
authors.initials: L
authors.lastname: Grin
authors.affiliation: Division of Infectious Diseases, Detroit Medical Center, Wayne State University, Detroit, MI, USA.
authors.forename: Kayoko
authors.initials: K
authors.lastname: Hayakawa
authors.affiliation: Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
authors.forename: Coral
authors.initials: C
authors.lastname: Shefler
authors.affiliation: Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
authors.forename: Tal
authors.initials: T
authors.lastname: Azouri
authors.affiliation: Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
authors.forename: Tamir
authors.initials: T
authors.lastname: Kaplansky
authors.affiliation: Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
authors.forename: Moran
authors.initials: M
authors.lastname: Maskit
authors.affiliation: Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
authors.forename: Tsilia
authors.initials: T
authors.lastname: Lazarovitch
authors.affiliation: Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.
authors.forename: Ronit
authors.initials: R
authors.lastname: Zaidenstein
authors.affiliation: Division of Infectious Diseases, Detroit Medical Center, Wayne State University, Detroit, MI, USA.
authors.forename: Keith S
authors.initials: KS
authors.lastname: Kaye
authors.affiliation: Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel. drormarchaim@gmail.com.|Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, 70300, Israel. drormarchaim@gmail.com.
authors.forename: Dror
authors.initials: D
authors.lastname: Marchaim
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D016470:Bacteremia / Q000188:drug therapy*; D001426:Bacterial Proteins / Q000378:metabolism*; D003661:Decision Support Techniques; D004756:Enterobacteriaceae Infections / Q000188:drug therapy*; D005260:Female; D006801:Humans; D007557:Israel; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D014481:United States; D018440:beta-Lactam Resistance; D001618:beta-Lactamases / Q000378:metabolism*
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D001618:beta-Lactamases; C063912:carbapenemase