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Lee IR, Thein TL, Ang LW, Ding Y, Lim JJ, Bok CF, Mukherjee S, Titin C, Kalimuddin S, Archuleta S, Lye DC. Cefazolin versus ceftriaxone as definitive treatment for Klebsiella pneumoniae bacteraemia: a retrospective multicentre study in Singapore. J Antimicrob Chemother 2021; 76:1303-1310. [PMID: 33501978 DOI: 10.1093/jac/dkab009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Ceftriaxone is the preferred treatment for bacteraemia caused by non-MDR (antibiotic-susceptible) Klebsiella pneumoniae. Excessive and widespread ceftriaxone use creates selection pressure for ESBLs. Cefazolin is an alternative, although there are theoretical concerns that SHV-1 β-lactamase in K. pneumoniae may inactivate cefazolin in an inoculum-dependent manner. OBJECTIVES In this retrospective study, we investigated the outcomes in K. pneumoniae bacteraemia patients treated with IV cefazolin versus IV ceftriaxone as definitive therapy. METHODS A total of 917 patients infected with K. pneumoniae from 1 January to 31 December 2016 in three public acute care hospitals in Singapore were screened for study eligibility. Consecutive unique episodes of monomicrobial bacteraemia caused by cefazolin- and/or ceftriaxone-susceptible K. pneumoniae were analysed (n = 284). RESULTS There were 143 patients (50.4%) in the cefazolin group and 141 patients (49.6%) in the ceftriaxone group. Demographics, baseline illness severity and risk factors for healthcare-associated bacteraemia were comparable in the two treatment groups. The primary outcome of 28 day all-cause mortality was not significantly different between the cefazolin and ceftriaxone groups (10.5% versus 7.1%, P = 0.403). Both in the crude analysis and using a multivariable logistic regression model with inverse probability weighting based on propensity score, cefazolin treatment was not associated with increased risk of 28 day mortality (OR 1.51 with ceftriaxone as the reference group, 95% CI 0.67-3.53; adjusted OR 1.55, 95% CI 0.33-7.40). CONCLUSIONS Cefazolin may be a ceftriaxone-sparing alternative treatment for antibiotic-susceptible K. pneumoniae bacteraemia. This observation may provide sufficient clinical equipoise for a randomized controlled trial.
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Affiliation(s)
- I Russel Lee
- National Centre for Infectious Diseases, Singapore
| | | | - Li Wei Ang
- National Centre for Infectious Diseases, Singapore
| | - Ying Ding
- National Centre for Infectious Diseases, Singapore
| | | | | | - Shilpa Mukherjee
- Division of Infectious Diseases, National University Hospital, National University Health System, Singapore
| | - Christina Titin
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Sophia Archuleta
- Division of Infectious Diseases, National University Hospital, National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - David C Lye
- National Centre for Infectious Diseases, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
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Hsieh CC, Chen PL, Lee CH, Yang CY, Lee CC, Ko WC. Definitive Cefazolin Therapy for Stabilized Adults with Community-Onset Escherichia coli, Klebsiella Species, and Proteus mirabilis Bacteremia: MIC Matters. J Clin Med 2020; 9:jcm9010157. [PMID: 31936020 PMCID: PMC7019784 DOI: 10.3390/jcm9010157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/30/2019] [Accepted: 01/06/2020] [Indexed: 01/21/2023] Open
Abstract
Background: Cefazolin is in vitro active against wild isolates of Escherichia coli, Klebsiella species, and Proteus mirabilis (EKP), but clinical evidence supporting the contemporary susceptibility breakpoint issued by the Clinical and Laboratory Standards Institute (CLSI) are limited. Methods: Between 2010 and 2015, adults with monomicrobial community-onset EKP bacteremia with definitive cefazolin treatment (DCT) at two hospitals were analyzed. Cefazolin minimum inhibitory concentrations (MICs) were correlated with clinical outcomes, including primary (treatment failure of DCT) and secondary (30-day mortality after bacteremia onset, recurrent bacteremia, and mortality within 90 days after the end of DCT) outcomes. Results: Overall, 466 bacteremic episodes, including 340 (76.2%) episodes due to E. coli, 90 (20.2%) Klebsiella species, and 16 (3.6%) P. mirabilis isolates, were analyzed. The mean age of these patients was 67.8 years and female-predominated (68.4%). A crude 15- and 30-day mortality rate was 0.7% and 2.2%, respectively, and 11.2% experienced treatment failure of DCT. A significant linear-by-linear association of cefazolin MICs, with the rate of treatment failure, 30-day crude mortality, recurrent bacteremia or 90-day mortality after the DCT was present (all γ = 1.00, p = 0.01). After adjustment, the significant impact of cefazolin MIC breakpoint on treatment failure and 30-day crude mortality was most evident in 2 mg/L (>2 mg/L vs. ≤2 mg/L; adjusted hazard ratio, 3.69 and 4.79; p < 0.001 and 0.02, respectively). Conclusion: For stabilized patients with community-onset EKP bacteremia after appropriate empirical antimicrobial therapy, cefazolin might be recommended as a definitive therapy for cefazolin-susceptible EKP bacteremia, based on the contemporary CLSI breakpoint.
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Affiliation(s)
- Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (C.-C.H.); (C.-H.L.); (C.-Y.Y.)
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan;
| | - Chung-Hsun Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (C.-C.H.); (C.-H.L.); (C.-Y.Y.)
| | - Chao-Yung Yang
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (C.-C.H.); (C.-H.L.); (C.-Y.Y.)
| | - Ching-Chi Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; (C.-C.H.); (C.-H.L.); (C.-Y.Y.)
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan;
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan 70142, Taiwan
- Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan 71101, Taiwan
- Correspondence: (C.-C.L.); (W.-C.K.); Tel.: +886-6-2748316 (C.-C.L.); +886-6-2353535 (ext. 3596) (W.-C.K.); Fax: +886-6-2990586 (C.-C.L.); +886-6-2752038 (W.-C.K.)
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan;
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (C.-C.L.); (W.-C.K.); Tel.: +886-6-2748316 (C.-C.L.); +886-6-2353535 (ext. 3596) (W.-C.K.); Fax: +886-6-2990586 (C.-C.L.); +886-6-2752038 (W.-C.K.)
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Chen CP, Liu MF, Lin CF, Lin SP, Shi ZY. The association of molecular typing, vancomycin MIC, and clinical outcome for patients with methicillin-resistant Staphylococcus aureus infections. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 50:619-626. [PMID: 26497450 DOI: 10.1016/j.jmii.2015.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/28/2015] [Accepted: 08/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE There are reports of an increase in vancomycin minimum inhibitory concentration (MIC) against methicillin-resistant Staphylococcus aureus (MRSA) over time, a phenomenon referred to as "MIC creep", but some studies have conflicting results. The aim of this study is to evaluate the association of molecular typing, vancomycin MIC, and clinical outcome for patients with MRSA infections. METHODS Thirty-two MRSA isolates from Taichung Veterans General Hospital (TCVGH), Taichung, Taiwan during the period of 2003 to 2008 were analyzed for the association of sequence typing, vancomycin MIC, and the correlated clinical outcome for patients with MRSA infections. The vancomycin MICs of 28 additional isolates from 2014 were used for the detection of MIC creep. RESULTS Among the genotypes of 32 isolates, there were 17 (53.1%) isolates with ST239-SCCmecIII, seven (21.9%) isolates with ST5-SCCmecII, six (18.8%) isolates with ST59-SCCmecIV, and two (6.2%) isolates with ST59-SCCmecVT. Two isolates had an MIC of 2 μg/mL and were identified as ST239-SCCmecIII. No statistically significant change in the distribution of MICs of all isolates was observed between 2003 and 2014 (p = 0.263). There was no significant difference in the mortality rates between two groups of patients with vancomycin MICs < 2 μg/mL and ≥ 2 μg/mL (p = > 0.99). CONCLUSION There was no vancomycin MIC creep in the period from 2003 to 2014 in this study. Appropriate prognostic models for assessment of the association among sequence types, vancomycin MICs, and clinical outcome warrant further investigation.
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Affiliation(s)
- Cheng-Pin Chen
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meei-Fang Liu
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chin-Fu Lin
- Microbiology Section of the Medical Laboratory, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Pin Lin
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Zhi-Yuan Shi
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.
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