Photosensitivity induced by lomefloxacin versus other fluoroquinolones: A meta-analysis

Lomefloxacin may be more likely than other fluoroquinolones to cause photosensitivity. However, the rate of photosensitivity is variable and a meta-analysis has yet to be performed. The aim of this meta-analysis is to compare the rate of photosensitivity between outpatients who received lomefloxacin and those who received other fluoroquinolones. PubMed, EMBASE, Cochrane Library databases and trial registries were searched for randomized controlled trials (RCTs) of outpatients through June 12, 2019. The study outcome was the rate of photosensitivity based on the intention-to-treat principle, estimated by risk difference (RD) as the primary analysis and Peto odds ratio (Peto OR) as the secondary analysis, with 95% confidence intervals (CIs) using random-effects models. Four RCTs (total of 2295 patients) were included in this meta-analysis. A statistically higher risk of photosensitivity was found with lomefloxacin than with other fluoroquinolones (RD, 3.4%; 95% CI, 0.7%-6.2%; P-value = 0.013; I² = 10.9%). The odds of photosensitivity was also significantly higher with lomefloxacin (Peto OR, 5.81; 95% CI, 3.34 to 10.11; P-value <0.001; I² = 0%). This meta-analysis of RCTs found significantly higher photosensitivity with lomefloxacin compared to other fluoroquinolones. Considering this finding and given its lack of additional efficacy compared to other fluoroquinolones, lomefloxacin as a fluoroquinolone option should potentially be reconsidered.

Systematic review and meta-analysis of the safety of erythromycin compared to clarithromycin in adults and adolescents with pneumonia

Macrolides are recommended for the treatment of community-acquired pneumonia (CAP). It is debatable whether erythromycin is associated with more adverse drug reactions (ADRs) compared to clarithromycin, and both are recommended in clinical practice guidelines. This meta-analysis aim is to compare ADRs in CAP patients treated with erythromycin versus clarithromycin. Two investigators independently searched PubMed, EMBASE and Cochrane Library databases through Feb 07, 2019. Randomized-controlled trials (RCTs) comparing ADRs of monotherapy with erythromycin versus with clarithromycin in adults or adolescents with CAP were included. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using random-effects models and evaluated heterogeneity (I²). Bias risk was assessed using the Cochrane risk of bias tool for RCTs. Five RCTs (total of 693 patients) were included. A significantly higher discontinuation rate due to ADRs was found with erythromycin compared with clarithromycin (RR, 4.347; 95% CI, 2.506-7.539; p < 0.001; I²=0%). Overall, ADRs occurred more significantly with erythromycin compared with clarithromycin (RR, 1.773; 95% CI, 1.423-2.209; p < 0.001; I²=0%). Gastrointestinal (GI) ADRs were higher with erythromycin (RR, 2.678; 95% CI, 1.791-4.006; p < 0.001; I²=5.835%). Restriction of analyses to double-blind RCTs did not change our findings. Based on meta-analysis of RCTs in adults and adolescents with CAP, erythromycin results in more overall ADRs and GI ADRs, as well as a higher rate of discontinuation due to ADRs. Therefore, given that erythromycin is not more effective than clarithromycin, erythromycin should not be selected unless other macrolides cannot be used.

Plazomicin: A Novel Aminoglycoside for the Treatment of Resistant Gram-Negative Bacterial Infections

Plazomicin is a novel semisynthetic parenteral aminoglycoside that inhibits bacterial protein synthesis. It was approved by the United States Food and Drug Administration for use in adults with complicated urinary tract infections (cUTI), including pyelonephritis. Plazomicin displays potent in vitro activity against Enterobacteriaceae, including both extended-spectrum β-lactamase-producing and carbapenem-resistant isolates. Plazomicin's enhanced Enterobacteriaceae activity is due to its stability to commonly encountered aminoglycoside-modifying enzymes that compromise the activity of traditional aminoglycosides. Plazomicin resistance in Enterobacteriaceae is via modification of the ribosomal binding site due to expression of 16S rRNA methyltransferases. Plazomicin does not display improved activity over traditional aminoglycosides against other problematic resistant Gram-negative bacteria, namely Pseudomonas aeruginosa and Acinetobacter baumannii. Plazomicin has been assessed in two phase III randomized controlled trials. The EPIC trial compared plazomicin and meropenem for the management of cUTI. In this trial, plazomicin demonstrated superiority in composite cure (81.7% vs 70.1%; difference 11.6%; 95% confidence interval [CI] 2.7-25.7) at the test-of-cure visit, which was driven by enhanced sustained microbiological eradication. The CARE trial compared plazomicin-based and colistin-based combinations in patients with serious infections due to carbapenem-resistant Enterobacteriaceae (CRE). In this analysis, plazomicin-based combinations were associated with numerically decreased mortality or serious disease-related complications when compared with colistin-based combinations (23.5% vs 50%, respectively; 90% CI -0.7 to 51.2). Furthermore, plazomicin was also associated with a lower incidence of nephrotoxicity than colistin. However, small sample sizes limit the interpretation of the findings in the CARE trial. Plazomicin is a novel aminoglycoside that offers clinicians an additional option for the management of CRE infections, with superior activity compared with traditional aminoglycosides and potentially improved efficacy and decreased toxicity compared with colistin.

Cefdinir-induced red stool and purple discoloration of nutritional formula: A case report

This case report describes a 4-year-old girl with food aversion who received three separate courses of cefdinir mixed with PediaSure®, an iron-fortified nutritional formula. The patient's stool turned red with variable onset during all three courses of treatment. Moreover, the PediaSure® formula turned purple after mixed with cefdinir, an interaction that has not been previously reported. We recommend that medication counseling for pediatric patients taking cefdinir include a mention of these possible discolorations.

Clinical cure with ceftriaxone versus ceftaroline or ceftobiprole in the treatment of staphylococcal pneumonia: a systematic review and meta-analysis

Ceftriaxone is an empirical antibiotic commonly used to treat pneumonia. However, its use to treat infections caused by methicillin-susceptible Staphylococcus aureus (MSSA) is controversial given limited evidence of its clinical efficacy. The objective of this study was to compare the clinical efficacy of ceftriaxone with either ceftaroline or ceftobiprole in the treatment of pneumonia caused by MSSA. A systematic review and meta-analysis of randomised controlled trials (RCTs) comparing clinical cure in patients with pneumonia who received ceftriaxone versus those who received either ceftaroline or ceftobiprole was conducted. Patients who received ceftriaxone plus vancomycin were excluded. The PubMed, Embase and Cochrane Library databases as well as clinical trial registries were searched up to 8 June 2018. Risk differences (RDs) with 95% confidence intervals (CIs) were estimated using a random-effects model and assessing for heterogeneity (I2). A total of five RCTs met the inclusion criteria; four used ceftaroline and one used ceftobiprole. Four studies included adults and one included paediatric patients. The adult studies included non-intensive care unit patients with mild-to-moderate community-acquired pneumonia. Clinical cure was statistically lower with ceftriaxone (RD, -28.5%, 95% CI -53.5% to -3.4%; P = 0.026; I2 = 16.321%) than with ceftaroline or ceftobiprole. In conclusion, ceftriaxone use was associated with higher clinical failure of MSSA pneumonia compared with ceftaroline or ceftobiprole. This supports the notion that ceftriaxone is not an ideal agent for the treatment of MSSA infections and adds new evidence against its use for MSSA pneumonia.

Impact of requiring re-authorization of restricted antibiotics on day 3 of therapy

Background

Pre-authorization of restricted antibiotics is a core component of an antibiotic stewardship programme (ASP). On day 3, information about culture results and clinical status is typically available. Our objective was to compare an ASP that requires initial authorization alone with one requiring initial authorization and re-authorization on day 3 of therapy.

Methods

A single-centre, retrospective, before and after study was conducted. Randomly selected adults were eligible if receiving a restricted antibiotic for ≥3 days during April to June in 2012 (pre-intervention) and during the same months in 2013 (post-intervention). The target sample size was 166 patients. The intervention required re-authorization of restricted antibiotics that were continuing on day 3. The days of therapy of restricted antibiotic(s), length of hospital stay (LOS) and hospital mortality were compared between pre- and post-intervention periods.

Results

The ASP intervention was associated with a decrease in median days of therapy from 5 (4-9) to 4 (3-5) days (P < 0.001) for all restricted agents, from 5 (3-6) to 3 (3-5) days for broad-spectrum Gram-negative agents (P < 0.001) and from 6.5 (6-7) to 3 (3-4.5) days for oral vancomycin. The proportion of subjects receiving restricted agents for >4 days decreased from 57.8% to 30.1% (P < 0.001). LOS decreased from 8 (5-17) to 6 (5-9) days (P = 0.005) without a significant change in hospital mortality.

Conclusions

Requiring re-authorization of restricted antibiotics on day 3 of therapy in addition to initial authorization was associated with reduction in overall consumption of restricted antibiotics and LOS without adversely affecting hospital mortality.

422. Brucellosis Regimens Comparison in a Saudi Tertiary Academic Medical Center

Background

Brucellosis is a zoonotic infectious disease caused by Brucella spp. that affects multiple body systems and may lead to several complications. Saudi Arabia is one of the countries where brucellosis is endemic. The purpose of this study was to describe the epidemiological characteristics of brucellosis as well as assessing outcomes of different antibiotic regimens.

Methods

A retrospective cohort study was conducted in a Saudi tertiary academic medical center. Eligible patients were adults with confirmed brucellosis (via culture, antibody test, or both) seen between January 2008 and March 2018 who received antibiotic therapy. Endpoints included clinical cure, all-cause mortality, and length of stay (LOS). Data were analyzed using ANOVA and chi-square. A P-value of < 0.05 was considered statistically significant.

Results

Out of 580 patients screened, 79 met the criteria and were included in the study. Based on the most common regimens prescribed, patients were divided into three groups, doxycycline–rifampin–aminoglycoside (DRA) with 39 patients, doxycycline–rifampin (DR) with 28 patients, and other regimens with 12 patients. All groups did not differ in their baseline characteristics except for the location (mostly outpatients or inpatients and very few in the intensive care unit), duration of therapy, and the presence of co-infection (most patients did not have co-infections). The most common risk factor was consumption of raw dairy products and most patients had both B. melitensis and B abortus in their culture and/or antibody test. There was no significant difference between the groups in terms of clinical cure, all-cause mortality, LOS, and end of therapy temperature, white blood cells counts, C-reactive protein levels, and erythrocyte sedimentation rates.

Conclusion

Due to lack of differences in clinical outcomes, all-cause mortality, LOS, and end of therapy parameters between the three groups, a regimen comprising two, rather than three, agents (namely doxycycline and rifampin) can be sufficient. Such finding complies with previous studies although replacing rifampin with an aminoglycoside might be superior per the World Health Organization guidelines for the treatment of brucellosis. Further studies with a larger sample size are warranted to confirm these findings.

Disclosures

All authors: No reported disclosures.

Impact of carbapenem versus non-carbapenem treatment on the rates of superinfection: A meta-analysis of randomized controlled trials

Imipenem and meropenem are the recommended antipseudomonal carbapenems for nosocomial pneumonia per clinical practice guidelines. However, these agents have a relatively broader spectrum of activity than other antibiotics and need to be reserved. Carbapenems might cause higher rate of superinfection. The aim of this study was to compare the rate of superinfection between patients who received imipenem or meropenem versus those who received non-carbapenem treatment. PubMed, EMBASE, Cochrane Library databases and two trial registries were searched for relevant randomized controlled trials of hospitalized adults with pneumonia through February 24, 2017 without date or language restrictions. Risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using random-effects models. The primary outcome was based on the intention-to-treat analysis while clinically evaluable patients were analyzed as secondary outcome. Eight RCTs were included in this meta-analysis. A statistically higher risk of superinfection with low heterogeneity (RR = 1.690, 95% CI 1.247-2.291, p = 0.001, I² = 0%) was associated with the two carbapenems compared to non-carbapenems. However, in comparison with non-carbapenems, superinfection with imipenem was significantly higher (RR = 1.694, 95% CI 1.234-2.325, p = 0.001, I² = 0%), while it was non-significant with meropenem (RR = 1.647, 95% CI 0.552-4.919, p = 0.371, I² = 0%). Superinfection was statistically higher in both double-blind and open-label studies and when carbapenems were compared to other antipseudomonal beta-lactams. This meta-analysis identified significantly higher superinfection with imipenem compared to non-carbapenems. The findings confirm the theory of higher superinfections with broader spectrum agents and provide additional support for reserving carbapenems for the treatment of infections caused by multidrug-resistant organisms.

Oral Vancomycin Monotherapy Versus Combination Therapy in Solid Organ Transplant Recipients With Uncomplicated Clostridium difficile Infection: A Retrospective Cohort Study

INTRODUCTION

Solid organ transplant (SOT) recipients are at high risk of Clostridium difficile infection (CDI) and CDI recurrence due to their suppressed immune systems and antibiotic exposure. A combination of metronidazole and oral vancomycin is often prescribed for SOT recipients with uncomplicated CDI despite any clinical practice guidelines supporting the need for combination therapy. This study aims to compare the CDI recurrence rates of metronidazole/vancomycin combination therapy to oral vancomycin monotherapy in SOT recipients after a first episode of uncomplicated CDI.

METHODS

A single-center retrospective cohort study evaluated SOT recipients diagnosed with uncomplicated CDI who were treated with vancomycin monotherapy or vancomycin/metronidazole combination therapy. The primary endpoint was CDI recurrence defined as a second CDI episode within 8 weeks of completing index CDI therapy. The secondary endpoints were time between the end of CDI therapy and recurrence, length of total hospitalization after the index CDI, and length of hospitalization after index CDI diagnosis.

RESULTS

Fifteen patients (25%) of 61 subjects experienced CDI recurrence. There was no statistically significant difference in CDI recurrence rate between the vancomycin monotherapy group and combination therapy group (23% versus 27%, respectively; P = .715). The median total length of hospitalization between the vancomycin monotherapy and combination therapy groups was statistically significant (9 versus 14 days, respectively; P = .047).

DISCUSSION

There was no difference found in recurrence rate between oral vancomycin monotherapy versus combination therapy. The study result weakens the practice of prescribing combination therapy for uncomplicated CDI in SOT recipients.

Systematic Review and Meta-analysis of the Safety of Antistaphylococcal Penicillins Compared to Cefazolin

Recent studies and experience suggest that cefazolin might be equally as effective as antistaphylococcal penicillins for methicillin-susceptible Staphylococcus aureus (MSSA), with a better safety profile and lower cost. The objective of these meta-analyses was to compare the safeties of antistaphylococcal penicillins and cefazolin. The PubMed, Embase, and International Pharmaceutical Abstracts databases and websites for clinical trial registries through 23 June 2017 were searched. In addition, recent abstracts from infectious disease and pharmacy conferences were reviewed. We estimated Peto odds ratios (ORs) with 95% confidence intervals (CIs) using random-effects models. One analysis focused on hospitalized patients, and the other focused on outpatients. Eleven retrospective studies of hospitalized patients and three retrospective studies of outpatients were included. In hospitalized patients, lower rates of nephrotoxicity (Peto OR, 0.225; 95% CI, 0.127 to 0.513), acute interstitial nephritis (Peto OR, 0.189; 95% CI, 0.053 to 0.675), hepatotoxicity (Peto OR, 0.160; 95% CI, 0.066 to 0.387), and drug discontinuation due to adverse reactions (Peto OR, 0.192; 95% CI, 0.089 to 0.414) were found with cefazolin. In outpatients, lower rates of nephrotoxicity (Peto OR, 0.372; 95% CI, 0.192 to 0.722), hepatotoxicity (Peto OR, 0.313; 95% CI, 0.156 to 0.627), and hypersensitivity reactions (Peto OR, 0.372; 95% CI, 0.201 to 0.687) were observed with cefazolin. Compared to antistaphylococcal penicillins, cefazolin was associated with significant reductions in nephrotoxicity and hepatotoxicity in hospitalized patients and outpatients. Additionally, cefazolin was associated with lower likelihoods of discontinuation due to side effects in hospitalized patients and hypersensitivity reactions in outpatients. Cefazolin should be considered a first-line option for patients with MSSA infections for which efficacy is presumed to be similar to that of antistaphylococcal penicillin therapy.

Nafcillin versus cefazolin for the treatment of methicillin-susceptible Staphylococcus aureus bacteremia

BACKGROUND

Anti-staphylococcal penicillins have long been the first-line treatment option for methicillin-susceptible Staphylococcus aureus (MSSA) infections. Recent retrospective data comparing nafcillin and cefazolin report similar clinical efficacy despite concerns about high inoculum MSSA infections.

METHODS

This was a retrospective, non-inferiority, cohort study comparing treatment failure rates between nafcillin and cefazolin in patients with MSSA bacteremia from any source, other than meningitis. Multiple logistic regression was used to adjust for confounding variables.

RESULTS

A total of 142 patients were included in the study. The overall treatment failure rate among patients receiving cefazolin was non-inferior to nafcillin (11.3% versus 8.5%; 90% confidence interval -5.2% to 10.8%). Rates of adverse drug events were significantly higher in the nafcillin arm (19.7% versus 7%; p=0.046). After adjustment for confounding variables, no difference between treatment groups was found in treatment failure (adjusted odds ratio (OR)=1.2; 95% CI, 0.3-4.5), but nafcillin was associated with significantly higher nephrotoxicity (adjusted odds ratio (OR)=5.4; 95% CI, 1.1-26.8).

CONCLUSION

Cefazolin was associated with lower nephrotoxicity and similar treatment failure rates compared to nafcillin suggesting that cefazolin is an appealing first line agent for most MSSA bloodstream infections.

Clinical failure with and without empiric atypical bacteria coverage in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis

Background

Both typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a β-lactam) to a regimen without atypical antibiotic coverage (β-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints).

Methods

We searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I²) was observed.

Results

Five RCTs with a total of 2011 patients were retained. A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732–0.99; P = 0.037]; I² = 0%). The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259–1.165, P = 0.118], I² = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523–1.272, P = 0.369], I² = 0%), diarrhea (RR = 0.746 [95% CI, 0.311–1.790, P = 0.512], I² = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542–1.270, P = 0.39], I² = 0%).

Conclusions

Empiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP. Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage. Our findings provide support for the current guidelines recommendations to include empiric atypical coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2495-5) contains supplementary material, which is available to authorized users.