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Meschiari M, Asquier-Khati A, Tiseo G, Luque-Paz D, Murri R, Boutoille D, Falcone M, Mussini C, Tattevin P. Treatment of infections caused by multidrug-resistant Gram-negative bacilli: A practical approach by the Italian (SIMIT) and French (SPILF) Societies of Infectious Diseases. Int J Antimicrob Agents 2024; 64:107186. [PMID: 38688353 DOI: 10.1016/j.ijantimicag.2024.107186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/13/2024] [Accepted: 04/24/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION The emergence of multidrug-resistant Gram-negative bacilli and the development of new antibiotics have complicated the selection of optimal regimens. International guidelines are valuable tools, but are limited by the scarcity of high-quality randomized trials in many situations. METHODS A panel of experts from the French and Italian Societies of Infectious Diseases aimed to address unresolved issues in clinical practice based on their experience, an updated literature review and open discussions. RESULTS The panel reached consensus for the following 'first choices': (i) cefepime for ventilator-acquired pneumonia due to AmpC β-lactamase-producing Enterobacterales; (ii) the β-lactam/β-lactamase inhibitor combination most active in vitro, or cefiderocol combined with fosfomycin, and aerosolized colistin or aminoglycosides, for severe pneumonia due to Pseudomonas aeruginosa resistant to ceftolozane-tazobactam; (iii) high-dose piperacillin-tazobactam (including loading dose and continuous infusion) for complicated urinary tract infections (cUTIs) caused by extended-spectrum β-lactamase-producing Enterobacterales with piperacillin-tazobactam minimum inhibitory concentration (MIC) ≤8 mg/L; (iv) high-dose cefepime for cUTIs due to AmpC β-lactamase-producing Enterobacterales other than Enterobacter spp. if cefepime MIC ≤2 mg/L; (v) ceftolozane-tazobactam or ceftazidime-avibactam plus metronidazole for intra-abdominal infections (IAIs) due to third-generation cephalosporin-resistant Enterobacterales; (vi) ceftazidime-avibactam plus aztreonam plus metronidazole for IAIs due to metallo-β-lactamase-producing Enterobacterales; (vii) ampicillin-sulbactam plus colistin for bloodstream infections (BSIs) caused by carbapenem-resistant Acinetobacter baumannii; (viii) meropenem-vaborbactam for BSIs caused by Klebsiella pneumoniae carbapenemase-producing Enterobacterales; and (ix) ceftazidime-avibactam plus fosfomycin for neurological infections caused by carbapenem-resistant P. aeruginosa. CONCLUSIONS These expert choices were based on the necessary balance between antimicrobial stewardship principles and the need to provide optimal treatment for individual patients in each situation.
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Affiliation(s)
- Marianna Meschiari
- Infectious Diseases Unit, Azienda Ospedaliera-Universitaria of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Antoine Asquier-Khati
- Infectious Diseases Department, Nantes University Hospital, INSERM CIC 1413, Nantes, France
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - David Luque-Paz
- Infectious Diseases and Intensive Care Units, Pontchaillou University Hospital, Rennes, France
| | - Rita Murri
- Infectious Diseases, Fondazione Policlinico Gemelli IRCCS Rome, Italy
| | - David Boutoille
- Infectious Diseases Department, Nantes University Hospital, INSERM CIC 1413, Nantes, France
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, Azienda Ospedaliera-Universitaria of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Units, Pontchaillou University Hospital, Rennes, France.
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Hoellinger B, Kaeuffer C, Boyer P, Lefebvre N, Hansmann Y, Robert A, Severac F, Gravet A, Danion F, Ruch Y, Ursenbach A. Cefepime vs carbapenems for treating third-generation cephalosporin-resistant AmpC β-lactamase-hyperproducing Enterobacterales bloodstream infections: a multicenter retrospective study. Int J Infect Dis 2023; 134:273-279. [PMID: 37453486 DOI: 10.1016/j.ijid.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES AmpC β-lactamase-hyperproducing Enterobacterales (ABLHE) bloodstream infections (BSI) are emerging and leading to therapeutic challenges worldwide. Prescriptions of carbapenems may lead to the emergence of resistance. This study aimed to compare cefepime with carbapenems for the treatment of third-generation cephalosporin-resistant ABLHE BSI. METHODS This retrospective multicenter study included patients with ABLHE BSI from two tertiary hospitals in France, between July 2017 and July 2022. Non-AmpC-producing Enterobacterales, extended-spectrum β-lactamase, and carbapenemase-producing Enterobacterales were excluded. Cefepime was prescribed only in case of minimal inhibitory concentration ≤1 mg/l. The primary outcome was 30-day in-hospital mortality from the date of index blood culture. Secondary outcomes were infection recurrence and treatment toxicity. An inverse probability of treatment weighting approach was used to balance the baseline characteristics between the two groups. RESULTS We analyzed 164 BSI, which included 77 in the cefepime group and 87 in the carbapenem group. In the weighted cohort, the 30-day mortality rates were similar between the cefepime group (23.3%) and the carbapenem group (19.6%) with a relative risk of 1.19 (95% confidence interval, 0.61-2.33 P = 0.614). No significant difference in recurrence or toxicity was found between the two groups. CONCLUSION This study adds evidence in favor of the use of cefepime for treating third-generation cephalosporin-resistant ABLHE BSI in case of minimal inhibitory concentration ≤ 1 mg/l, which could spare carbapenems.
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Affiliation(s)
- Baptiste Hoellinger
- CHU de Strasbourg, service des Maladies Infectieuses et Tropicales, Strasbourg, France; Hôpital Emile Muller, service de Médecine Interne, Mulhouse, France
| | | | - Pierre Boyer
- CHU de Strasbourg, service de Bactériologie, Strasbourg, France
| | - Nicolas Lefebvre
- CHU de Strasbourg, service des Maladies Infectieuses et Tropicales, Strasbourg, France
| | - Yves Hansmann
- CHU de Strasbourg, service des Maladies Infectieuses et Tropicales, Strasbourg, France
| | - Amandine Robert
- CHU de Strasbourg, service de Réanimation Médicale Hautepierre, Strasbourg, France
| | - François Severac
- CHU de Strasbourg, Groupe Méthodes en Recherche Clinique (GMRC), Strasbourg, France
| | - Alain Gravet
- Hôpital Emile Muller, laboratoire de microbiologie, Mulhouse, France
| | - François Danion
- CHU de Strasbourg, service des Maladies Infectieuses et Tropicales, Strasbourg, France; Inserm UMR_S 1109, Laboratoire d'ImmunoRhumatologie Moléculaire, Strasbourg, France
| | - Yvon Ruch
- CHU de Strasbourg, service des Maladies Infectieuses et Tropicales, Strasbourg, France
| | - Axel Ursenbach
- CHU de Strasbourg, service des Maladies Infectieuses et Tropicales, Strasbourg, France.
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Ávila-Núñez M, Lima O, Sousa A, Represa M, Rubiñán P, Celestino P, Garrido-Ventín M, García-Formoso L, Vasallo-Vidal F, Martinez-Lamas L, Pérez-Landeiro A, Rubianes M, Pérez-Rodríguez MT. Carbapenem alternatives for treatment of bloodstream infections due to AmpC producing enterobacterales. Ann Clin Microbiol Antimicrob 2023; 22:75. [PMID: 37592268 PMCID: PMC10436381 DOI: 10.1186/s12941-023-00624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/29/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Carbapenems (CR) have traditionally been the first line treatment for bacteremia caused by AmpC-producing Enterobacterales. However, CR have a high ecological impact, and carbapenem-resistant strains continue rising. Thus, other treatment alternatives like Piperacillin-Tazobactam (P-T) or Cefepime (CEF) and oral sequential therapy (OST) are being evaluated. METHODS We conducted a retrospective, single-centre observational study. All adult patients with AmpC-producing Enterobacterales bacteremia were included. The primary endpoint was clinical success defined as a composite of clinical cure, 14-day survival, and no adverse events. We evaluated the evolution of patients in whom OST was performed. RESULTS Seventy-seven patients were included, 22 patients in the CR group and 55 in the P-T/CEF group (37 patients received CEF and 18 P-T). The mean age of the patients was higher in the P-T/CEF group (71 years in CR group vs. 76 years in P-T/CEF group, p = 0.053). In the multivariate analysis, age ≥ 70 years (OR 0.08, 95% CI [0.007-0.966], p = 0.047) and a Charlson index ≥ 3 (OR 0.16, 95% CI [0.026-0.984], p = 0.048), were associated with a lower clinical success. Treatment with P-T/CEF was associated with higher clinical success (OR 7.75, 95% CI [1.273-47.223], p = 0.026). OST was performed in 47% of patients. This was related with a shorter in-hospital stay (OST 14 days [7-22] vs. non-OST 18 days [13-38], p = 0.005) without difference in recurrence (OST 3% vs. non-OST 5%, p = 0.999). CONCLUSIONS Targeted treatment with P-T/CEF and OST could be safe and effective treatments for patients with AmpC-producing Enterobacterales bacteremia.
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Affiliation(s)
- M Ávila-Núñez
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - O Lima
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain.
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain.
| | - A Sousa
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
| | - M Represa
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - P Rubiñán
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - P Celestino
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - M Garrido-Ventín
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - L García-Formoso
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - F Vasallo-Vidal
- Microbiology Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - L Martinez-Lamas
- Microbiology Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - A Pérez-Landeiro
- Pharmacy Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - M Rubianes
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
| | - M T Pérez-Rodríguez
- Infectious Diseases Unit. Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Galicia, Spain
- Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
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Abstract
Class C β-lactamases or cephalosporinases can be classified into two functional groups (1, 1e) with considerable molecular variability (≤20% sequence identity). These enzymes are mostly encoded by chromosomal and inducible genes and are widespread among bacteria, including Proteobacteria in particular. Molecular identification is based principally on three catalytic motifs (64SXSK, 150YXN, 315KTG), but more than 70 conserved amino-acid residues (≥90%) have been identified, many close to these catalytic motifs. Nevertheless, the identification of a tiny, phylogenetically distant cluster (including enzymes from the genera Legionella, Bradyrhizobium, and Parachlamydia) has raised questions about the possible existence of a C2 subclass of β-lactamases, previously identified as serine hydrolases. In a context of the clinical emergence of extended-spectrum AmpC β-lactamases (ESACs), the genetic modifications observed in vivo and in vitro (point mutations, insertions, or deletions) during the evolution of these enzymes have mostly involved the Ω- and H-10/R2-loops, which vary considerably between genera, and, in some cases, the conserved triplet 150YXN. Furthermore, the conserved deletion of several amino-acid residues in opportunistic pathogenic species of Acinetobacter, such as A. baumannii, A. calcoaceticus, A. pittii and A. nosocomialis (deletion of residues 304-306), and in Hafnia alvei and H. paralvei (deletion of residues 289-290), provides support for the notion of natural ESACs. The emergence of higher levels of resistance to β-lactams, including carbapenems, and to inhibitors such as avibactam is a reality, as the enzymes responsible are subject to complex regulation encompassing several other genes (ampR, ampD, ampG, etc.). Combinations of resistance mechanisms may therefore be at work, including overproduction or change in permeability, with the loss of porins and/or activation of efflux systems.
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Contemporary Treatment of Resistant Gram-Negative Infections in Pediatric Patients. Infect Dis Clin North Am 2022; 36:147-171. [DOI: 10.1016/j.idc.2021.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Isler B, Harris P, Stewart AG, Paterson DL. An update on cefepime and its future role in combination with novel β-lactamase inhibitors for MDR Enterobacterales and Pseudomonas aeruginosa. J Antimicrob Chemother 2021; 76:550-560. [PMID: 33332545 DOI: 10.1093/jac/dkaa511] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cefepime, a wide-spectrum β-lactam antibiotic, has been in use for the treatment of serious bacterial infections for almost 25 years. Since its clinical development, there has been a dramatic shift in its dosing, with 2 g every 8 hours being preferred for serious infections to optimize pharmacokinetic/pharmacodynamic considerations. The advent of ESBLs has become a threat to its ongoing use, although future coadministration with β-lactamase inhibitors (BLIs) under development is an area of intense study. There are currently four new cefepime/BLI combinations in clinical development. Cefepime/zidebactam is generally active against MBL-producing Enterobacterales and Pseudomonas aeruginosa, in vitro and in animal studies, and cefepime/taniborbactam has activity against KPC and OXA-48 producers. Cefepime/enmetazobactam and cefepime/tazobactam are potential carbapenem-sparing agents with activity against ESBLs. Cefepime/enmetazobactam has completed Phase III and cefepime/taniborbactam is in Phase III clinical studies, where they are being tested against carbapenems or piperacillin/tazobactam for the treatment of complicated urinary tract infections. While these combinations are promising, their role in the treatment of MDR Gram-negative infections can only be determined with further clinical studies.
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Affiliation(s)
- Burcu Isler
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Patrick Harris
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Adam G Stewart
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - David L Paterson
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Pot M, Reynaud Y, Couvin D, Ducat C, Ferdinand S, Gravey F, Gruel G, Guérin F, Malpote E, Breurec S, Talarmin A, Guyomard-Rabenirina S. Wide Distribution and Specific Resistance Pattern to Third-Generation Cephalosporins of Enterobacter cloacae Complex Members in Humans and in the Environment in Guadeloupe (French West Indies). Front Microbiol 2021; 12:628058. [PMID: 34248862 PMCID: PMC8268024 DOI: 10.3389/fmicb.2021.628058] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 05/31/2021] [Indexed: 11/25/2022] Open
Abstract
Species belonging to Enterobacter cloacae complex have been isolated in numerous environments and samples of various origins. They are also involved in opportunistic infections in plants, animals, and humans. Previous prospection in Guadeloupe (French West Indies) indicated a high frequency of E. cloacae complex strains resistant to third-generation cephalosporins (3GCs) in a local lizard population (Anolis marmoratus), but knowledge of the distribution and resistance of these strains in humans and the environment is limited. The aim of this study was to compare the distribution and antibiotic susceptibility pattern of E. cloacae complex members from different sources in a “one health” approach and to find possible explanations for the high level of resistance in non-human samples. E. cloacae complex strains were collected between January 2017 and the end of 2018 from anoles, farm animals, local fresh produce, water, and clinical human samples. Isolates were characterized by the heat-shock protein 60 gene-fragment typing method, and whole-genome sequencing was conducted on the most frequent clusters (i.e., C-VI and C-VIII). The prevalence of resistance to 3GCs was relatively high (56/346, 16.2%) in non-human samples. The associated resistance mechanism was related to an AmpC overproduction; however, in human samples, most of the resistant strains (40/62) produced an extended-spectrum beta-lactamase. No relation was found between resistance in isolates from wild anoles (35/168) and human activities. Specific core-genome phylogenetic analysis highlighted an important diversity in this bacterial population and no wide circulation among the different compartments. In our setting, the mutations responsible for resistance to 3GCs, especially in ampD, were diverse and not compartment specific. In conclusion, high levels of resistance in non-human E. cloacae complex isolates are probably due to environmental factors that favor the selection of these resistant strains, and this will be explored further.
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Affiliation(s)
- Matthieu Pot
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
| | - Yann Reynaud
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
| | - David Couvin
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
| | - Célia Ducat
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
| | - Séverine Ferdinand
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
| | - François Gravey
- GRAM 2.0, Normandie University, UNICAEN, UNIROUEN, Caen, France
| | - Gaëlle Gruel
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
| | - François Guérin
- GRAM 2.0, Normandie University, UNICAEN, UNIROUEN, Caen, France.,Department of Clinical Microbiology, Caen University Hospital, Caen, France
| | - Edith Malpote
- Laboratory of Clinical Microbiology, University Hospital of Guadeloupe, Pointe-à-Pitre/Les Abymes, France
| | - Sébastien Breurec
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France.,Faculty of Medicine Hyacinthe Bastaraud, University of the Antilles, Pointe-à-Pitre, France.,Centre for Clinical Investigation 1424, INSERM, Pointe-à-Pitre/Les Abymes, France
| | - Antoine Talarmin
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Les Abymes, France
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Cefepime use: A need for antimicrobial stewardship. Infect Dis Now 2021; 51:445-450. [PMID: 33960301 DOI: 10.1016/j.idnow.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/30/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Unlike other 3GCs, Cefepime is a cephalosporin that has, in animal model studies, shown a low risk of selecting resistant mutants. It also enables carbapenems to be saved in treatment of Pseudomonasaeruginosa and the CESP group (Citrobacter, Enterobacter, Serratia and Providencia, as well as the genus Klebsiellaaerogenes, Morganella and Hafnia), consequently producing cephalosporinase. We aimed to determine whether its prescription in a French teaching hospital met criteria for proper use. PATIENTS AND METHODS We conducted a retrospective study of proper cefepime use between March 1st, 2018 and February 28th, 2019, to assess indication, antimicrobial stewardship, dosing schedule, microbiological documentation, reevaluation, and treatment duration. Prescriptions were then compared to local guidelines established from international literature. RESULTS Out of 142 cefepime prescriptions, 97.2% were prescribed as validated according to indication. The duration of the documented treatments matched the guidelines for 56.5% of patients, dosage was adapted to the indication for 77.4% and to kidney function for 97.2%. Bacteriological documentation was performed in all cases and an antibiogram was generated in 99.2% of cases. The treatment was reassessed between 48 and 72h and between the 7th and 10th day for 44.2% and 60.9% of the prescriptions respectively. The antimicrobial stewardship team managed half of the prescriptions. Only 13.4% of prescriptions met all criteria for proper use. CONCLUSION Notwithstanding a highly sizable majority of validated indications, a very small proportion of cefepime prescriptions met all the criteria for proper use. In the context of increased cefepime consumption, which is favored by its increased place in the latest recommendations published in 2019, proper use of cefepime prescriptions needs to be more effectively promoted.
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Laufenberg Née Kohlmann R, Gatermann SG. Species-specific Epidemiology of AmpC Production. Clin Infect Dis 2020; 71:2767-2768. [PMID: 32022849 DOI: 10.1093/cid/ciaa120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- Rebekka Laufenberg Née Kohlmann
- Department of Medical Microbiology, Ruhr-Universität Bochum, Bochum, Germany
- Microbiology, MVZ SYNLAB Leverkusen GmbH, Leverkusen, Germany
| | - Sören G Gatermann
- Department of Medical Microbiology, Ruhr-Universität Bochum, Bochum, Germany
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