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Salinas-Botrán A, Olmos-Blanco C, Fernández de Velasco-Pérez D, Guzmán-Carreras A, Morales-Rosas A, Gómez-Ramírez D. Dalbavancin as consolidation antibiotic treatment in infective endocarditis, cardiac implantable electronic devices infection and bacteremia: Clinical experience of 7 years. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2024:S2529-993X(24)00128-X. [PMID: 38763866 DOI: 10.1016/j.eimce.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 02/22/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Dalbavancin (DBV), a novel lipoglycopeptide with activity against Gram-positive bacterial infections, is approved for the treatment of acute bacterial skin and skin structure infections (ABSSSIs). It has linear dose-related pharmacokinetics allowing a prolonged interval between doses. It would be a good option for the treatment of patients with Gram-positive cardiovascular infections. METHODS Retrospective analysis of patients with cardiovascular infection (infective endocarditis, bacteremia, implantable electronic device infection) treated with DBV at Hospital Clínico San Carlos (Madrid) for 7 years (2016-2022). Patients were divided in two study groups: 1) Infective endocarditis (IE), 2) Bacteremia. Epidemiological, clinical, microbiological and therapeutic data were analyzed. RESULTS A total of 25 patients were treated with DBV for cardiovascular infection. IE was the most common indication (68%), followed by bacteremia (32%) with male predominance in both groups (64% vs 62%) and median age of 67,7 and 57,5 years, respectively. 100% of blood cultures were positive to Gram-positive microorganisms (Staphylococcus spp., Streptococcus spp. or Enterococcus spp.) in both study groups. Previously to DBV, all patients received other antibiotic therapy, both in the group of IE (median: 80 days) as in bacteremia (14,8 days). The main reason for the administration of DBV was to continue intravenous antimicrobial therapy outside the hospital in both the EI group (n = 15) and the bacteremia group (n = 8). DBV was used as consolidation therapy in a once- or twice-weekly regimen. Microbiological and clinical successes were reached in 84% of cases (n = 21), 76,4% in IE group and 100% in bacteremia group. No patient documented adverse effects during long-term dalbavancin treatment. CONCLUSION DBV is an effective and safety treatment as consolidation antibiotic therapy in IE and bacteremia produced by Gram-positive microorganisms.
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Affiliation(s)
- Alejandro Salinas-Botrán
- Servicio de Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain.
| | - Carmen Olmos-Blanco
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
| | | | | | | | - Daniel Gómez-Ramírez
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
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Kaasch AJ, López-Cortés LE, Rodríguez-Baño J, Cisneros JM, Dolores Navarro M, Fätkenheuer G, Jung N, Rieg S, Lepeule R, Coutte L, Bernard L, Lemaignen A, Kösters K, MacKenzie CR, Soriano A, Hagel S, Fantin B, Lafaurie M, Talarmin JP, Dinh A, Guimard T, Boutoille D, Welte T, Reuter S, Kluytmans J, Martin ML, Forestier E, Stocker H, Vitrat V, Tattevin P, Rommerskirchen A, Noret M, Adams A, Kern WV, Hellmich M, Seifert H. Efficacy and safety of an early oral switch in low-risk Staphylococcus aureus bloodstream infection (SABATO): an international, open-label, parallel-group, randomised, controlled, non-inferiority trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:523-534. [PMID: 38244557 DOI: 10.1016/s1473-3099(23)00756-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Staphylococcus aureus bloodstream infection is treated with at least 14 days of intravenous antimicrobials. We assessed the efficacy and safety of an early switch to oral therapy in patients at low risk for complications related to S aureus bloodstream infection. METHODS In this international, open-label, randomised, controlled, non-inferiority trial done in 31 tertiary care hospitals in Germany, France, the Netherlands, and Spain, adult patients with low-risk S aureus bloodstream infection were randomly assigned after 5-7 days of intravenous antimicrobial therapy to oral antimicrobial therapy or to continue intravenous standard therapy. Randomisation was done via a central web-based system, using permuted blocks of varying length, and stratified by study centre. The main exclusion criteria were signs and symptoms of complicated S aureus bloodstream infection, non-removable foreign devices, and severe comorbidity. The composite primary endpoint was the occurrence of any complication related to S aureus bloodstream infection (relapsing S aureus bloodstream infection, deep-seated infection, and mortality attributable to infection) within 90 days, assessed in the intention-to-treat population by clinical assessors who were masked to treatment assignment. Adverse events were assessed in all participants who received at least one dose of study medication (safety population). Due to slow recruitment, the scientific advisory committee decided on Jan 15, 2018, to stop the trial after 215 participants were randomly assigned (planned sample size was 430 participants) and to convert the planned interim analysis into the final analysis. The decision was taken without knowledge of outcome data, at a time when 126 participants were enrolled. The new sample size accommodated a non-inferiority margin of 10%; to claim non-inferiority, the upper bound of the 95% CI for the treatment difference (stratified by centre) had to be below 10 percentage points. The trial is closed to recruitment and is registered with ClinicalTrials.gov (NCT01792804), the German Clinical trials register (DRKS00004741), and EudraCT (2013-000577-77). FINDINGS Of 5063 patients with S aureus bloodstream infection assessed for eligibility, 213 were randomly assigned to switch to oral therapy (n=108) or to continue intravenous therapy (n=105). Mean age was 63·5 (SD 17·2) years and 148 (69%) participants were male and 65 (31%) were female. In the oral switch group, 14 (13%) participants met the primary endpoint versus 13 (12%) in the intravenous group, with a treatment difference of 0·7 percentage points (95% CI -7·8 to 9·1; p=0·013). In the oral switch group, 36 (34%) of 107 participants in the safety population had at least one serious adverse event compared with 27 (26%) of 103 participants in the intravenous group (p=0·29). INTERPRETATION Oral switch antimicrobial therapy was non-inferior to intravenous standard therapy in participants with low-risk S aureus bloodstream infection. However, it is necessary to carefully assess patients for signs and symptoms of complicated S aureus bloodstream infection at the time of presentation and thereafter before considering early oral switch therapy. FUNDING Deutsche Forschungsgemeinschaft. TRANSLATIONS For the German, Spanish, French and Dutch translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty, Otto von Guericke University Magdeburg, Magdeburg, Germany.
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - José Miguel Cisneros
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - M Dolores Navarro
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS)/CSIC, Department of Medicine, Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Gerd Fätkenheuer
- Department I of Internal Medicine, University Clinics, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, University Clinics, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Raphaël Lepeule
- Antimicrobial Stewardship Team, Department of Prevention, Diagnosis, and Treatment of Infections, Henri-Mondor University Hospital, Creteil, France
| | - Laetitia Coutte
- Antimicrobial Stewardship Team, Department of Prevention, Diagnosis, and Treatment of Infections, Henri-Mondor University Hospital, Creteil, France
| | - Louis Bernard
- Service de Médecine Interne et Maladies Infectieuses, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Adrien Lemaignen
- Service de Médecine Interne et Maladies Infectieuses, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Katrin Kösters
- Medical Clinic II-Clinic for Gastroenterology, Hepatology, Neurogastroenterology, Infectious Diseases, Hematology, Oncology and Palliative Medicine, Helios Klinikum Krefeld, Krefeld, Germany
| | - Colin R MacKenzie
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), CIBERINFEC, Barcelona, Spain
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany
| | - Bruno Fantin
- Internal Medicine Department, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris, Clichy, France
| | | | | | - Aurélien Dinh
- Infectious Diseases Department, Raymond-Poincaré University Hospital, Garches, France
| | - Thomas Guimard
- Infectious Diseases Department, CHD Vendée, La Roche-sur-Yon, France
| | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, INSERM, Nantes, France
| | - Tobias Welte
- Clinic for Respiratory Medicine and Infectious Diseases, Member of the German Center of Lung Research, Medical School Hannover, Hannover, Germany
| | - Stefan Reuter
- Department of Infectious Diseases and General Internal Medicine, Department of Infection Control, Klinikum Leverkusen, Leverkusen, Germany
| | - Jan Kluytmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Maria Luisa Martin
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitari Son Espases, Fundació Institut d'Investigació Sanitària Illes Balears, Palma de Mallorca, Spain
| | - Emmanuel Forestier
- Infectious Diseases Department, Centre Hospitalier Métropole Savoie, Chambéry, France
| | - Hartmut Stocker
- Klinik für Infektiologie, St Joseph Hospital Berlin Tempelhof, Berlin, Germany
| | - Virginie Vitrat
- Infectious Diseases Unit, Centre Hospitalier d'Annecy Genevois, Epagny Metz-Tessy, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Anna Rommerskirchen
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marion Noret
- French National Network of Clinical Research in Infectious Diseases, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University Medical Centre Freiburg, Freiburg, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany; Institute of Translational Research, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
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Veillette JJ, May SS, Alzaidi S, Olson J, Butler AM, Waters CD, Jackson K, Hutton MA, Webb BJ. Real-World Effectiveness of Intravenous and Oral Antibiotic Stepdown Strategies for Gram-Negative Complicated Urinary Tract Infection With Bacteremia. Open Forum Infect Dis 2024; 11:ofae193. [PMID: 38665174 PMCID: PMC11045028 DOI: 10.1093/ofid/ofae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
Background Robust data are lacking regarding the optimal route, duration, and antibiotic choice for gram-negative bloodstream infection from a complicated urinary tract infection source (GN-BSI/cUTI). Methods In this multicenter observational cohort study, we simulated a 4-arm registry trial using a causal inference method to compare effectiveness of the following regimens for GN-BSI/cUTI: complete course of an intravenous β-lactam (IVBL) or oral stepdown therapy within 7 days using fluoroquinolones (FQs), trimethoprim-sulfamethoxazole (TMP-SMX), or high-bioavailability β-lactams (HBBLs). Adults treated between January 2016 and December 2022 for Escherichia coli or Klebsiella species GN-BSI/cUTI were included. Propensity weighting was used to balance characteristics between groups. The 60-day recurrence was compared using a multinomial Cox proportional hazards model with probability of treatment weighting. Results Of 2571 patients screened, 759 (30%) were included. Characteristics were similar between groups. Compared with IVBLs, we did not observe a difference in effectiveness for FQs (adjusted hazard ratio, 1.09 [95% confidence interval, .49-2.43]) or TMP-SMX (1.44 [.54-3.87]), and the effectiveness of TMP-SMX/FQ appeared to be optimal at durations of >10 days. HBBLs were associated with nearly 4-fold higher risk of recurrence (adjusted hazard ratio, 3.83 [95% confidence interval, 1.76-8.33]), which was not mitigated by longer treatment durations. Most HBBLs (67%) were not optimally dosed for bacteremia. Results were robust to multiple sensitivity analyses. Conclusions These real-world data suggest that oral stepdown therapy with FQs or TMP-SMX have similar effectiveness as IVBLs. HBBLs were associated with higher recurrence rates, but dosing was suboptimal. Further data are needed to define optimal dosing and duration to mitigate treatment failures.
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Affiliation(s)
- John J Veillette
- Infectious Diseases Telehealth Service, Intermountain Health, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Stephanie S May
- Infectious Diseases Telehealth Service, Intermountain Health, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Sameer Alzaidi
- Pharmacy Services, Intermountain Health, Taylorsville, Utah, USA
| | - Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah, USA
- Division of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Allison M Butler
- Statistical Data Center, Intermountain Health, Murray, Utah, USA
| | - C Dustin Waters
- Department of Pharmacy, McKay-Dee Hospital, Ogden, Utah, USA
| | - Katarina Jackson
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Mary A Hutton
- Department of Pharmacy, Utah Valley Hospital, Provo, Utah, USA
| | - Brandon J Webb
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
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Alzaidi S, Veillette JJ, May SS, Olson J, Jackson K, Waters CD, Butler AM, Hutton MA, Buckel WR, Webb BJ. Oral β-Lactams, Fluoroquinolones, or Trimethoprim-Sulfamethoxazole for Definitive Treatment of Uncomplicated Escherichia coli or Klebsiella Species Bacteremia From a Urinary Tract Source. Open Forum Infect Dis 2024; 11:ofad657. [PMID: 38370295 PMCID: PMC10873539 DOI: 10.1093/ofid/ofad657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Indexed: 02/20/2024] Open
Abstract
Background Fluoroquinolones (FQs) are effective for oral step-down therapy for gram-negative bloodstream infections but are associated with unfavorable toxic effects. Robust data are lacking for trimethoprim-sulfamethoxazole (TMP-SMX) and high-bioavailability β-lactams (HBBLs). Methods In this multicenter observational cohort study, we simulated a 3-arm registry trial using causal inference methods to compare the effectiveness of FQs, TMP-SMX, or HBBLs for gram-negative bloodstream infections oral step-down therapy. The study included adults treated between January 2016 and December 2022 for uncomplicated Escherichia coli or Klebsiella species bacteremia of urinary tract origin who were who were transitioned to an oral regimen after ≤4 days of effective intravenous antibiotics. Propensity weighting was used to balance characteristics between groups. 60-day recurrence was compared using a multinomial Cox proportional hazards model with probability of treatment weighting. Results Of 2571 patients screened, 648 (25%) were included. Their median age (interquartile range) was 67 (45-78) years, and only 103 (16%) were male. Characteristics were well balanced between groups. Compared with FQs, TMP-SMX had similar effectiveness (adjusted hazard ratio, 0.91 [95% confidence interval, .30-2.78]), and HBBLs had a higher risk of recurrence (2.19 [.95-5.01]), although this difference was not statistically significant. Most HBBLs (70%) were not optimally dosed for bacteremia. A total antibiotic duration ≤8 days was associated with a higher recurrence rate in select patients with risk factors for failure. Conclusions FQs and TMP-SMX had similar effectiveness in this real-world data set. HBBLs were associated with higher recurrence rates but suboptimal dosing may have contributed. Further studies are needed to define optimal BL dosing and duration to mitigate treatment failures.
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Affiliation(s)
- Sameer Alzaidi
- Department of Pharmacy, Intermountain Health, Taylorsville, Utah, USA
| | - John J Veillette
- Infectious Diseases Telehealth Service, Intermountain Health, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Stephanie S May
- Infectious Diseases Telehealth Service, Intermountain Health, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Jared Olson
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Katarina Jackson
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - C Dustin Waters
- Department of Pharmacy, McKay-Dee Hospital, Ogden, Utah, USA
| | - Allison M Butler
- Statistical Data Center, Intermountain Health, Murray, Utah, USA
| | - Mary A Hutton
- Department of Pharmacy, Utah Valley Hospital, Provo, Utah, USA
| | - Whitney R Buckel
- Department of Pharmacy, Intermountain Health, Taylorsville, Utah, USA
| | - Brandon J Webb
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
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Bolton WJ, Wilson R, Gilchrist M, Georgiou P, Holmes A, Rawson TM. Personalising intravenous to oral antibiotic switch decision making through fair interpretable machine learning. Nat Commun 2024; 15:506. [PMID: 38218885 PMCID: PMC10787786 DOI: 10.1038/s41467-024-44740-2] [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: 05/05/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024] Open
Abstract
Antimicrobial resistance (AMR) and healthcare associated infections pose a significant threat globally. One key prevention strategy is to follow antimicrobial stewardship practices, in particular, to maximise targeted oral therapy and reduce the use of indwelling vascular devices for intravenous (IV) administration. Appreciating when an individual patient can switch from IV to oral antibiotic treatment is often non-trivial and not standardised. To tackle this problem we created a machine learning model to predict when a patient could switch based on routinely collected clinical parameters. 10,362 unique intensive care unit stays were extracted and two informative feature sets identified. Our best model achieved a mean AUROC of 0.80 (SD 0.01) on the hold-out set while not being biased to individuals protected characteristics. Interpretability methodologies were employed to create clinically useful visual explanations. In summary, our model provides individualised, fair, and interpretable predictions for when a patient could switch from IV-to-oral antibiotic treatment. Prospectively evaluation of safety and efficacy is needed before such technology can be applied clinically.
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Affiliation(s)
- William J Bolton
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK.
- AI4Health Centre for Doctoral Training, Imperial College London, London, UK.
- Department of Computing, Imperial College London, London, UK.
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.
| | - Richard Wilson
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK
| | - Mark Gilchrist
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Pantelis Georgiou
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London, UK
| | - Alison Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Timothy M Rawson
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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Tingsgård S, Bastrup Israelsen S, Jørgensen HL, Østergaard C, Benfield T. Early Switch From Intravenous to Oral Antibiotics for Patients With Uncomplicated Gram-Negative Bacteremia. JAMA Netw Open 2024; 7:e2352314. [PMID: 38261322 PMCID: PMC10807296 DOI: 10.1001/jamanetworkopen.2023.52314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/19/2023] [Indexed: 01/24/2024] Open
Abstract
Importance Gram-negative bacteremia is a global health concern, and optimizing the transition from intravenous (IV) to oral antibiotics is a critical step in improving patient treatment and resource utilization. Objective To assess the association of switching to oral antibiotics within 4 days after initial blood culture with 90-day all-cause mortality compared with prolonged IV antibiotic treatment for patients with uncomplicated gram-negative bacteremia. Design, Setting, and Participants This cohort study conducted using the target trial emulation framework included observational data from adults with uncomplicated gram-negative bacteremia in 4 hospitals in Copenhagen, Denmark, from January 1, 2018, through December 31, 2021. The duration of follow-up was 90 days. Eligibility criteria included a blood culture positive for growth of gram-negative bacteria, clinical stability within 4 days of initial blood culture, an available susceptibility report on day 4, and initiation of appropriate empirical IV antibiotic treatment within 24 hours of blood culture. Exposure Switching to oral antibiotics within 4 days after initial blood culture compared with continuing IV antibiotic treatment for at least 5 days after initial blood culture. Main Outcomes and Measures The main outcome was 90-day all-cause mortality. Inverse probability of treatment weighting was applied to adjust for confounding. Intention-to-treat and per-protocol analyses were performed using pooled logistic regression to estimate absolute risk, risk difference (RD), and risk ratio (RR); 95% CIs were computed using bootstrapping. Results A total of 914 individuals were included in the target trial emulation analysis (512 [56.0%] male; median age, 74.5 years [IQR, 63.3-83.2 years]); 433 (47.4%) transitioned early to oral antibiotic treatment, and 481 (52.6%) received prolonged IV treatment. Ninety-nine individuals (10.8%) died during follow-up. The proportion of individuals who died was higher in the group receiving prolonged IV treatment (69 [14.3%] vs 30 [6.9%]). In the intention-to-treat analysis, 90-day all-cause mortality risk was 9.1% (95% CI, 6.7%-11.6%) for the early-switch group and 11.7% (95% CI, 9.6%-13.8%) for the group receiving prolonged IV treatment; the RD was -2.5% (95% CI, -5.7% to 0.7%) and RR was 0.78 (95% CI, 0.60-1.10). In the per-protocol analysis, the RD was -0.1% (95% CI, -3.4% to 3.1%) and RR was 0.99 (95% CI, 0.70-1.40). Conclusions and Relevance In this cohort study of uncomplicated gram-negative bacteremia, early transition to oral antibiotics within 4 days of initial blood culture was associated with 90-day all-cause mortality risk comparable to that of continuing IV antibiotic treatment and may be an effective alternative to prolonged IV treatment.
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Affiliation(s)
- Sandra Tingsgård
- Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital–Amager and Hvidovre, Hvidovre, Denmark
| | - Simone Bastrup Israelsen
- Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital–Amager and Hvidovre, Hvidovre, Denmark
| | - Henrik Løvendahl Jørgensen
- Department of Clinical Biochemistry, Copenhagen University Hospital–Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Østergaard
- Department of Clinical Microbiology, Copenhagen University Hospital–Amager and Hvidovre, Hvidovre, Denmark
| | - Thomas Benfield
- Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital–Amager and Hvidovre, Hvidovre, Denmark
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Eleftheriotis G, Marangos M, Lagadinou M, Bhagani S, Assimakopoulos SF. Oral Antibiotics for Bacteremia and Infective Endocarditis: Current Evidence and Future Perspectives. Microorganisms 2023; 11:3004. [PMID: 38138148 PMCID: PMC10745436 DOI: 10.3390/microorganisms11123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Bacteremia and endocarditis are two clinical syndromes that, for decades, were managed exclusively with parenteral antimicrobials, irrespective of a given patient's clinical condition, causative pathogen, or its antibiotic susceptibility profile. This clinical approach, however, was based on low-quality data and outdated expert opinions. When a patient's condition has improved, gastrointestinal absorption is not compromised, and an oral antibiotic regimen reaching adequate serum concentrations is available, a switch to oral antibacterials can be applied. Although available evidence has reduced the timing of the oral switch in bacteremia to three days/until clinical improvement, there are only scarce data regarding less than 10-day intravenous antibiotic therapy in endocarditis. Many standard or studied oral antimicrobial dosages are smaller than the approved doses for parenteral administration, which is a risk factor for treatment failure; in addition, the gastrointestinal barrier may affect drug bioavailability, especially when the causative pathogen has a minimum inhibitory concentration that is close to the susceptibility breakpoint. A considerable number of patients infected by such near-breakpoint strains may not be potential candidates for oral step-down therapy to non-highly bioavailable antibiotics like beta-lactams; different breakpoints should be determined for this setting. This review will focus on summarizing findings about pathogen-specific tailoring of oral step-down therapy for bacteremia and endocarditis, but will also present laboratory and clinical data about antibiotics such as beta-lactams, linezolid, and fosfomycin that should be studied more in order to elucidate their role and optimal dosage in this context.
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Affiliation(s)
- Gerasimos Eleftheriotis
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
| | - Markos Marangos
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
| | - Maria Lagadinou
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
| | - Sanjay Bhagani
- Department of Infectious Diseases and HIV Medicine, Royal Free London NHS Foundation Trust, London NW3 2QG, UK;
| | - Stelios F. Assimakopoulos
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
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8
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Gandhi K, Wrzesinski M, Bunnell K, Gibble A. Oral antibiotic step-down therapy for nonstaphylococcal gram-positive bloodstream infections. Diagn Microbiol Infect Dis 2023; 107:116068. [PMID: 37774630 DOI: 10.1016/j.diagmicrobio.2023.116068] [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: 01/29/2023] [Revised: 08/03/2023] [Accepted: 08/18/2023] [Indexed: 10/01/2023]
Abstract
Bloodstream infections traditionally are treated with intravenous (IV) therapy. This study's purpose is to evaluate if oral step-down therapy is noninferior to IV therapy for gram-positive bloodstream infections (GP-BSIs). This retrospective cohort study included patients who received IV therapy and those who received oral step-down therapy for a nonstaphylococcal GP-BSI from 2017 to 2019. The primary endpoint was a composite outcome of 90-day all-cause mortality and clinical failure. A total of 308 patients were included (n = 94, oral; n = 214, IV). The oral step-down group had a lower incidence of 90-day clinical failure (9% vs 14%; P < 0.001). The IV group had a longer hospital stay (4 vs 6 days, P < 0.001); however, there were no significant differences in secondary outcomes. Bivariate analysis found no predictors of 90-day clinical failure. Oral step-down therapy was found to be noninferior to IV therapy.
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Affiliation(s)
- Kelvin Gandhi
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI, USA.
| | | | - Kristen Bunnell
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI, USA; Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, Milwaukee, WI USA
| | - Allison Gibble
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI, USA
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9
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Jung J, Cozzi F, Forrest GN. Using antibiotics wisely. Curr Opin Infect Dis 2023; 36:462-472. [PMID: 37732791 DOI: 10.1097/qco.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
PURPOSE OF REVIEW This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases. RECENT FINDINGS There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages. SUMMARY In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven. VIDEO ABSTRACT http://links.lww.com/COID/A50.
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Affiliation(s)
- Jae Jung
- Rush University Medical Center, Chicago, Illinois, USA
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10
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Joseph WS, Kosinski MA, Rogers LC. Parenteral Vancomycin in the Treatment of MRSA-Associated Diabetic Foot Infections: An Unnecessary Risk. INT J LOW EXTR WOUND 2023:15347346231207553. [PMID: 37886812 DOI: 10.1177/15347346231207553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Diabetic foot infections (DFIs) are a common and costly complication of diabetes. Soft tissue and bone infections in DFIs frequently lead to amputation and/or sepsis which can be costly for both the patient and the healthcare system. Staphylococcus aureus is the most commonly identified causative agent in DFIs, and people with diabetes may have an increased risk of infection with methicillin-resistant Staphylococcus aureus (MRSA). In addition to increased susceptibility to severe infection, MRSA in DFIs is associated with high rates of treatment failure, morbidity, and hospitalization costs meaning appropriate treatment is a high priority. While hospitalized patients are usually treated with intravenous (IV) vancomycin, this can be costly in terms of inpatient stays, staffing costs, and adverse events. For example, vancomycin-associated acute kidney injury not only delays hospital discharge and increases costs but is also a particular concern for patients with diabetes who already have an increased risk of kidney problems. Vancomycin-resistant strains of S. aureus have also been identified, which means that alternative treatment options may need to be explored. Treatment alternatives to IV vancomycin, including oral antibiotics, have been shown to provide similar efficacy, with reduced costs, outpatient or home-based administration, and with fewer serious adverse effects. Although infectious disease specialists often use IV vancomycin alone, or in combination, as a first-line therapeutic option, they are increasingly seeing the value of outpatient or at-home oral antibiotics as an alternative. This manuscript reviews the evidence for true costs of vancomycin therapy for MRSA-associated DFIs and examines the alternatives.
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Affiliation(s)
- Warren S Joseph
- Arizona College of Podiatric Medicine, Midwestern University, Glendale, AZ, USA
| | - Mark A Kosinski
- Department of Medicine, New York College of Podiatric Medicine, New York, NY, USA
| | - Lee C Rogers
- Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX, USA
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11
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Freling S, Wald-Dickler N, Banerjee J, Canamar CP, Tangpraphaphorn S, Bruce D, Davar K, Dominguez F, Norwitz D, Krishnamurthi G, Fung L, Guanzon A, Minejima E, Spellberg M, Spellberg C, Baden R, Holtom P, Spellberg B. Real-World Application of Oral Therapy for Infective Endocarditis: A Multicenter, Retrospective, Cohort Study. Clin Infect Dis 2023; 77:672-679. [PMID: 36881940 DOI: 10.1093/cid/ciad119] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We sought to compare the outcomes of patients treated with intravenous (IV)-only vs oral transitional antimicrobial therapy for infective endocarditis (IE) after implementing a new expected practice within the Los Angeles County Department of Health Services (LAC DHS). METHODS We conducted a multicentered, retrospective cohort study of adults with definite or possible IE treated with IV-only vs oral therapy at the 3 acute care public hospitals in the LAC DHS system between December 2018 and June 2022. The primary outcome was clinical success at 90 days, defined as being alive and without recurrence of bacteremia or treatment-emergent infectious complications. RESULTS We identified 257 patients with IE treated with IV-only (n = 211) or oral transitional (n = 46) therapy who met study inclusion criteria. Study arms were similar for many demographics; however, the IV cohort was older, had more aortic valve involvement, were hemodialysis patients, and had central venous catheters present. In contrast, the oral cohort had a higher percentage of IE caused by methicillin-resistant Staphylococcus aureus. There was no significant difference between the groups in clinical success at 90 days or last follow-up. There was no difference in recurrence of bacteremia or readmission rates. However, patients treated with oral therapy had significantly fewer adverse events. Multivariable regression adjustments did not find significant associations between any selected variables and clinical success across treatment groups. CONCLUSIONS These results demonstrate similar outcomes of real-world use of oral vs IV-only therapy for IE, in accord with prior randomized, controlled trials and meta-analyses.
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Affiliation(s)
- Sarah Freling
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Noah Wald-Dickler
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Josh Banerjee
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Catherine P Canamar
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Soodtida Tangpraphaphorn
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Dara Bruce
- Department of Integrative Anatomical Sciences, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Kusha Davar
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Fernando Dominguez
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Daniel Norwitz
- Department of Integrative Anatomical Sciences, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Ganesh Krishnamurthi
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Lilian Fung
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Ashley Guanzon
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Pharmacy, University of Southern California Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, California, USA
| | - Emi Minejima
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Pharmacy, University of Southern California Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, California, USA
| | - Michael Spellberg
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Catherine Spellberg
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Rachel Baden
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Paul Holtom
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Keck School of Medicine-University of Southern California, Los Angeles, California, USA
| | - Brad Spellberg
- Department of Medicine and Infectious Diseases, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
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12
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Phillips MC, Wald-Dickler N, Davar K, Lee R, Baden R, Holtom P, Spellberg B. Choosing patients over placebos: oral transitional therapy vs. IV-only therapy for bacteraemia and infective endocarditis. Clin Microbiol Infect 2023; 29:1126-1132. [PMID: 37179005 DOI: 10.1016/j.cmi.2023.04.030] [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: 01/31/2023] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The belief that antibiotics must be administered intravenously (IV) to treat bacteraemia and endocarditis has its origins 70 years ago and has engrained itself in the psyche of the medical community and the public at large. This has led to hesitancy in adopting evidence-based strategies utilizing oral transitional therapy for the treatment of these infections. We aim to reframe the narrative around this debate, focusing on patient safety over vestigial psychology. OBJECTIVES This narrative review summarizes the current state of the literature regarding the use of oral transitional therapy for the treatment of bacteraemia and infective endocarditis, focusing on studies comparing it to the traditional, IV-only approach. SOURCES Relevant studies and abstracts from PubMed reviewed in April 2023. CONTENT Treating bacteraemia with oral transitional therapy has been studied in 9 randomized controlled trials (RCTs), totalling 625 patients, as well as numerous large, retrospective cohorts, including 3 published in the last 5 years alone, totalling 4763 patients. We identified 3 large, retrospective cohort studies; one quasi-experimental, pre-post study, and 3 RCTs of patients with endocarditis, totalling 748 patients in the retrospective cohorts and 815 patients in prospective, controlled studies. In all these studies, no worse outcomes were observed in the oral transitional therapy arm as compared with IV-only therapy. The main difference has consistently been longer durations of inpatient hospitalization and increased risk of catheter-related adverse events like venous thrombosis and line-associated blood stream infections in the IV-only groups. IMPLICATIONS There are ample data showing that choosing oral therapy reduces hospital stay and has fewer adverse events for patients than IV-only therapy, all with similar or better outcomes. In selected patients, choosing IV-only therapy may serve more as an anxiolytic "placebo" for the patient and provider rather than a necessity for treating the actual infection.
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Affiliation(s)
- Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Noah Wald-Dickler
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rachel Baden
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Paul Holtom
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Brad Spellberg
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
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13
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Yetmar ZA, Chesdachai S, Lahr BD, Challener DW, Arensman Hannan KN, Epps K, Stevens RW, Seville MT, Tande AJ, Virk A. Comparison of Oral and Intravenous Definitive Antibiotic Therapy for Beta-Hemolytic Streptococcus Species Bloodstream Infections from Soft Tissue Sources: a Propensity Score-Matched Analysis. Antimicrob Agents Chemother 2023; 67:e0012023. [PMID: 37191533 PMCID: PMC10269088 DOI: 10.1128/aac.00120-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
Beta-hemolytic streptococci are common causes of bloodstream infection (BSI). There is emerging data regarding oral antibiotics for BSI but limited for beta-hemolytic streptococcal BSI. We conducted a retrospective study of adults with beta-hemolytic streptococcal BSI from a primary skin/soft tissue source from 2015 to 2020. Patients transitioned to oral antibiotics within 7 days of treatment initiation were compared to those who continued intravenous therapy, after propensity score matching. The primary outcome was 30-day treatment failure (composite of mortality, infection relapse, and hospital readmission). A prespecified 10% noninferiority margin was used for the primary outcome. We identified 66 matched pairs of patients treated with oral and intravenous antibiotics as definitive therapy. Based on an absolute difference in 30-day treatment failure of 13.6% (95% confidence interval 2.4 to 24.8%), the noninferiority of oral therapy was not confirmed (P = 0.741); on the contrary, the superiority of intravenous antibiotics is suggested by this difference. Acute kidney injury occurred in two patients who received intravenous treatment and zero who received oral therapy. No patients experienced deep vein thrombosis or other vascular complications related to treatment. In patients treated for beta-hemolytic streptococcal BSI, those who transitioned to oral antibiotics by day 7 showed higher rates of 30-day treatment failure than propensity-matched patients. This difference may have been driven by underdosing of oral therapy. Further investigation into optimal antibiotic choice, route, and dosing for definitive therapy of BSI is needed.
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Affiliation(s)
- Zachary A. Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian D. Lahr
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W. Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kevin Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan W. Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aaron J. Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abinash Virk
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Mponponsuo K, Brown KA, Fridman DJ, Johnstone J, Langford BJ, Lee SM, MacFadden DR, Patel SN, Schwartz KL, Daneman N. Highly versus less bioavailable oral antibiotics in the treatment of gram-negative bloodstream infections: a propensity-matched cohort analysis. Clin Microbiol Infect 2023; 29:490-497. [PMID: 36216237 DOI: 10.1016/j.cmi.2022.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In this study, we evaluated the clinical outcomes associated with the use of highly bioavailable oral antibiotics (fluoroquinolones and trimethoprim-sulfamethoxazole) compared with the less-bioavailable oral antibiotics (β-lactams) in gram-negative bloodstream infections (BSIs). METHODS Among hospitalized older adult patients in Ontario, Canada, discharged home on oral treatment for gram-negative BSI between 1 January 2017 and 31 December 2019, we used a matched cohort design to compare outcomes among those receiving highly versus less-bioavailable agents; hard-matching 1:1 on sex, BSI pathogen (Escherichia coli vs. non-E. coli), and infection source (urinary vs. non-urinary/unknown source) along with a propensity score, incorporating specific pathogen, patient, and infection characteristics. The primary outcome was the composite of 90-day all-cause mortality, recurrent BSI with the same pathogen (genus and species), and re-admission to any Ontario hospital. RESULTS A total of 2012 patients were included in the study (1006 in each bioavailability category). Those who received highly (compared with less) bioavailable antibiotics at discharge had lower rates of the composite outcome (171/1006 [17.0%] vs. 216/1006 [21.5%]), adjusted odds ratio being 0.74 (95% CI, 0.60-0.92). Recurrent BSI at 90 days was the main driver for the composite outcome occurring in 64 (5.4%) and 107 (9.4%) patients of the highly and less-bioavailable groups, respectively (p < 0.001) (adjusted odds ratio, 0.56; 95% CI, 0.40-0.78). DISCUSSION Use of highly (compared with less) bioavailable antibiotics at discharge was associated with significantly better clinical outcomes among patients with gram-negative BSIs.
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Affiliation(s)
- Kwadwo Mponponsuo
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.
| | - Kevin A Brown
- Public Health Ontario, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Daniel J Fridman
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jennie Johnstone
- Infection Prevention and Control, Sinai Health and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Bradley J Langford
- Public Health Ontario, Hotel Dieu Shaver Health and Rehabilitation Center, Toronto, Ontario, Canada
| | - Samantha M Lee
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Samir N Patel
- Public Health Ontario, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Institute for Clinical Evaluative Sciences, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
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15
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Caniff KE, Rebold N, Rybak MJ. Oral stepdown in Gram-positive bloodstream infections: A step in the right direction. Pharmacotherapy 2023; 43:247-256. [PMID: 36727285 DOI: 10.1002/phar.2775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 02/03/2023]
Abstract
Bloodstream infections (BSIs) due to Gram-positive organisms have traditionally been treated with prolonged courses of intravenous antimicrobials. However, this dogma is associated with substantial burden to the patient and health care system. Consequently, there is growing interest in the utilization of oral stepdown therapy, defined as the transition of intravenous therapy to an active oral agent, for this indication. This review highlights available literature examining oral stepdown in adult patients with BSI due to commonly encountered Gram-positive pathogens, including Staphylococcus aureus, Streptococcus spp., and Enterococcus spp. Support for oral stepdown in this setting is primarily derived from observational studies subject to selection bias. Nevertheless, this treatment strategy exhibits promising potential in carefully selected patients as it is consistently associated with reductions in hospital length of stay without jeopardizing clinical cure or survivability. Prospective, randomized trials are needed for validation of oral stepdown in Gram-positive BSI and to identify the optimal patient population and regimen.
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Affiliation(s)
- Kaylee E Caniff
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Nicholas Rebold
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Clinical & Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, District of Columbia, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Detroit Receiving Hospital, Detroit, Michigan, USA
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16
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Waked R, Craig WY, Mercuro NJ, Wungwattana M, Wood E, Rokas KE. Uncomplicated Streptococcal Bacteremia: The Era of Oral Antibiotic Step-down Therapy? Int J Antimicrob Agents 2023; 61:106736. [PMID: 36690120 PMCID: PMC10023366 DOI: 10.1016/j.ijantimicag.2023.106736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/28/2022] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND The purpose of this study was to compare the clinical outcomes of adults with uncomplicated streptococcal bacteremia who received either oral (PO) step-down or continued intravenous (IV) therapy. METHODS This was a retrospective, single-center, cohort study, including adults admitted with Streptococcal bloodstream infection between January 1, 2013, and December 31, 2020. Only patients with uncomplicated Streptococcal bloodstream infections were included. Patients who transitioned to PO therapy within 5 days from bacteremia onset were compared to patients receiving continued IV therapy. The primary outcome was clinical failure, defined by either 90-day hospital readmission or mortality. Secondary outcomes included hospital length of stay (LOS) and antibiotic-related adverse events (AAEs). RESULTS Of the 264 patients included, 42% were transitioned to PO therapy. Group B Streptococcus (22.7%) was the most common isolate. The most common sources of infection were skin and soft tissue (35%) and pulmonary (25%). Intensive care unit (ICU) stay was more common in the continued IV therapy group (22.2%) than in the PO step-down group (5.4%). The frequency of clinical failure was similar in the IV and PO groups (24.2% vs. 18.0%, P=0.23). The IV group had longer hospital LOS (median, [interquartile range (IQR)]) compared with the PO group (7 [5-13.5] vs. 4 [3-5] days, P<0.001). The incidence of AAEs was similar in the IV and PO groups (1.3% vs. 1.8%, P=0.74). CONCLUSION Oral antibiotic step-down therapy may be appropriate for the treatment of uncomplicated Streptococcal bacteremia, with consideration of factors such as patient comorbidities, type of infection, source control and clinical progress.
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Affiliation(s)
- Rami Waked
- Infectious Diseases, Maine Medical Center, Portland, Maine, USA
| | - Wendy Y Craig
- Maine Health Institute for Research, Scarborough, Maine, USA
| | | | | | - Emily Wood
- Infectious Diseases, Maine Medical Center, Portland, Maine, USA
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17
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Tamma PD, Cosgrove SE. Which trial do we need? Early oral antibiotic therapy for the treatment of gram-negative bloodstream infections. Clin Microbiol Infect 2023:S1198-743X(23)00082-4. [PMID: 36805881 DOI: 10.1016/j.cmi.2023.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Impact of specialty on the self-reported practice of using oral antibiotic therapy for definitive treatment of bloodstream infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e48. [PMID: 36970426 PMCID: PMC10031584 DOI: 10.1017/ash.2023.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/11/2023]
Abstract
Abstract
Background:
No established guidelines exist regarding the role of oral antibiotic therapy (OAT) to treat bloodstream infections (BSIs), and practices may vary depending on clinician specialty and experience.
Objective:
To assess practice patterns regarding oral antibiotic use for treatment of bacteremia in infectious diseases clinicians (IDCs, including physicians and pharmacists and trainees in these groups) and non–infectious diseases clinicians (NIDCs).
Design:
Open-access survey.
Participants:
Clinicians caring for hospitalized patients receiving antibiotics.
Methods:
An open-access, web-based survey was distributed to clinicians at a Midwestern academic medical center using e-mail and to clinicians outside the medical center using social media. Respondents answered questions regarding confidence prescribing OAT for BSI in different scenarios. We used χ2 analysis for categorical data evaluated association between responses and demographic groups.
Results:
Of 282 survey responses, 82.6% of respondents were physicians, 17.4% pharmacists, and IDCs represented 69.2% of all respondents. IDCs were more likely to select routine use of OAT for BSI due to gram-negative anaerobes (84.6% vs 59.8%; P < .0001), Klebsiella spp (84.5% vs 69.0%; P < .009), Proteus spp (83.6% vs 71.3%; P < .027), and other Enterobacterales (79.5% vs 60.9%; P < .004). Our survey results revealed significant differences in selected treatment of Staphylococcus aureus syndromes. Fewer IDCs than NIDCs selected OAT to complete treatment for methicillin-resistant S. aureus (MRSA) BSI due to gluteal abscess (11.9% vs 25.6%; P = .012) and methicillin-susceptible S. aureus (MSSA) BSI due to septic arthritis (13.9% vs 20.9%; P = .219).
Conclusions:
Practice variation and discordance with evidence for the use of OAT for BSIs exists among IDCs versus NIDCs, highlighting opportunities for education in both clinician groups.
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Davar K, Clark D, Centor RM, Dominguez F, Ghanem B, Lee R, Lee TC, McDonald EG, Phillips MC, Sendi P, Spellberg B. Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV. Open Forum Infect Dis 2022; 10:ofac706. [PMID: 36694838 PMCID: PMC9853939 DOI: 10.1093/ofid/ofac706] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.
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Affiliation(s)
- Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Devin Clark
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Robert M Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama, Birmingham, Alabama, USA
| | - Fernando Dominguez
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | | | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Brad Spellberg
- Correspondence: Brad Spellberg, MD, Hospital Administration, 2051 Marengo Street, Los Angeles, CA 90033 ()
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20
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Pradubkham T, Suwanpimolkul G, Gross AE, Nakaranurack C. Intravenous to oral transition of antibiotics for gram-negative bloodstream infection at a University hospital in Thailand: Clinical outcomes and predictors of treatment failure. PLoS One 2022; 17:e0273369. [PMID: 36137077 PMCID: PMC9499306 DOI: 10.1371/journal.pone.0273369] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 08/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Limited studies evaluate the outcome of intravenous antibiotics to oral transition in Gram-negative bloodstream infection (GN-BSI), particularly GN-BSI originating outside the urinary tract. This study aimed to evaluate treatment success in patients with GN-BSI treated with either intravenous therapy or intravenous to oral transition and to identify factors associated with treatment failure in those undergoing intravenous to oral transition. Methods A retrospective cohort study was conducted at King Chulalongkorn Memorial Hospital, Thailand. Patients were included if they were ≥18 years of age, hospitalized in general medical wards with GN-BSI between August 1, 2015, to July 31, 2020, received intravenous antibiotic agents and had a functioning gastrointestinal tract. Results Of 955 patients, 545 (57.1%) were in the intravenous to oral transition group. The urinary tract was the most common source of infection (38.8%). Ciprofloxacin was the most prescribed oral antibiotic (53%). Treatment success occurred in 94.3% in the intravenous antibiotic to oral transition group. There was no significant difference in treatment success between the two groups (P = 0.790) with a concordant result after using propensity score matching (P = 0.223). Independent predictors of treatment failure in the intravenous to oral transition group included metastatic solid cancer (aOR = 4.355), HIV infection with CD4 < 200 cells/mm3 (aOR = 8.452), qSOFA score ≥ 2 (aOR = 2.545), multidrug-resistant infection (aOR = 2.849), and respiratory tract infection (aOR = 8.447). Hospital length of stay in the intravenous to oral transition group was shorter than in the intravenous group (P < 0.001). Conclusions Intravenous to oral transition may be a practical approach in GN-BSI. Patients with Gram-negative bacteremia who have HIV infection with CD4 < 200 cells/mm3, multidrug-resistant infections, and respiratory tract sources of infection may not be ideal candidates for this approach. Future research is needed from a randomized controlled trial.
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Affiliation(s)
| | - Gompol Suwanpimolkul
- Faculty of Medicine, Division of Infectious Diseases, Department of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Alan Edward Gross
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Chotirat Nakaranurack
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
- * E-mail:
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21
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Thaden JT, Tamma PD, Pan Q, Doi Y, Daneman N. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac005. [PMID: 35156030 PMCID: PMC8827556 DOI: 10.1093/jacamr/dlac005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Trials supporting shorter durations of antibiotic therapy for Gram-negative bloodstream infections (GN-BSI) have recently been published. However, adoption of these findings into practice is unclear given limited eligibility criteria and relatively large non-inferiority margins of these studies. To better understand contemporary management of GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. Methods We developed and disseminated an online survey to assess practice patterns involving treatment duration of GN-BSI, including providers from 28 countries. χ2 tests, t-tests and multivariable linear regression with generalized estimating equations were used to identify factors associated with treatment duration. Results In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). The median reported duration of antibiotics was 7 days (IQR, 7–10 days) for all GN-BSI sources. Thirty percent of providers typically recommend durations that differ by ≥7 days depending on the source of GN-BSI, and 71% treat ≥10 days for at least one source. In an adjusted model, factors associated with increased duration included intra-abdominal (+1.01 days, 95% CI 0.57–1.45 days; P < 0.0001), vascular catheter (+0.74 days; 0.33–1.15 days; P = 0.0004), and respiratory (+0.76 days; 0.38–1.14 days; P < 0.0001) sources of GN-BSI relative to urinary sources. Providers that transition patients to oral therapy report shorter durations than those who treat with full IV therapy (−0.60 days; −1.12 to −0.09 days; P = 0.02). Conclusions There is extensive heterogeneity in duration of therapy for treating GN-BSI, particularly with respect to source of GN-BSI. Investigations into appropriate treatment durations for different GN-BSI sources are needed.
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Affiliation(s)
- Joshua T. Thaden
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Corresponding author. E-mail:
| | - Pranita D. Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qing Pan
- Department of Statistics, The George Washington University, Washington, DC, USA
| | - Yohei Doi
- Center for Innovative Antimicrobial Therapy, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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22
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The Ultra-Broad-Spectrum Beta-lactamase Inhibitor QPX7728 Restores the Potency of Multiple Oral Beta-lactam Antibiotics against Beta-lactamase Producing Strains of Resistant Enterobacterales. Antimicrob Agents Chemother 2021; 66:e0216821. [PMID: 34902261 PMCID: PMC8846479 DOI: 10.1128/aac.02168-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
QPX7728 is a cyclic boronate ultrabroad-spectrum beta-lactamase inhibitor, with potent activity against both serine beta-lactamases and metallo-beta-lactamases. QPX7728 can be delivered systemically by the intravenous (i.v.) or oral route of administration. Oral beta-lactam antibiotics alone or in combination with QPX7728 were evaluated for (i) sensitivity to hydrolysis by various common beta-lactamases and inhibition of hydrolysis by QPX7728, (ii) the impact of non-beta-lactamase-mediated resistance mechanisms on potency of beta-lactams, and (iii) in vitro activity against a panel of clinical strains producing diverse beta-lactamases. The carbapenem tebipenem had stability for many serine beta-lactamases from all molecular classes, followed by the cephalosporin ceftibuten. Addition of QPX7728 to tebipenem, ceftibuten, and amdinocillin completely reversed beta-lactamase-mediated resistance in cloned beta-lactamases from serine enzyme and metalloenzyme classes; the degree of potentiation of other beta-lactams varied according to the beta-lactamase produced. Tebipenem, ceftibuten, and cefixime had the lowest MICs against laboratory strains with various combinations of beta-lactamases and the intrinsic drug resistance mechanisms of porin and efflux mutations. There was a high degree of correlation between potency of various combinations against cloned beta-lactamases and efflux/porin mutants and the activity against clinical isolates, showing the importance of inhibition of beta-lactamase along with minimal impact of general intrinsic resistance mechanisms affecting the beta-lactam. Tebipenem and ceftibuten appeared to be the best beta-lactam antibiotics when combined with QPX7728 for activity against Enterobacterales that produce serine beta-lactamases or metallo-beta-lactamases.
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23
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Thaden JT, Tamma PD, Doi Y, Daneman N. Variability in oral antibiotic step-down therapy in the management of Gram-negative bloodstream infections. Int J Antimicrob Agents 2021; 58:106451. [PMID: 34653617 DOI: 10.1016/j.ijantimicag.2021.106451] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/21/2021] [Accepted: 10/02/2021] [Indexed: 10/20/2022]
Abstract
There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ2 tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48-2.61); P < 0.001], pneumonia [2.24 (1.67-2.99); P < 0.001], skin [7.26 (4.71-11.20); P < 0.001] and urinary [9.15 (5.73-14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57-7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23-53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation.
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Affiliation(s)
- Joshua T Thaden
- Division of Infectious Diseases, Duke University School of Medicine, DUMC Box 102359, Durham, NC 27701, USA.
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA
| | - Yohei Doi
- Center for Innovative Antimicrobial Therapy, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Scaife Hall, Suite 829, 3550 Terrace Street, Pittsburgh, PA 15213, USA; Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi 470-1192, Japan
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room G1 06, Toronto, ON, Canada M4N 3M5
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24
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Sutton JD, Stevens VW, Chang NCN, Khader K, Timbrook TT, Spivak ES. Oral β-Lactam Antibiotics vs Fluoroquinolones or Trimethoprim-Sulfamethoxazole for Definitive Treatment of Enterobacterales Bacteremia From a Urine Source. JAMA Netw Open 2020; 3:e2020166. [PMID: 33030555 PMCID: PMC7545306 DOI: 10.1001/jamanetworkopen.2020.20166] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/30/2020] [Indexed: 12/13/2022] Open
Abstract
Importance Oral β-lactam antibiotics are traditionally not recommended to treat Enterobacterales bacteremia because of concerns over subtherapeutic serum concentrations, but there is a lack of outcomes data, specifically after initial treatment with parenteral antibiotics. Given the limited data and increasing limitations of fluoroquinolones or trimethoprim-sulfamethoxazole (TMP-SMX), oral β-lactam antibiotics may be a valuable additional treatment option. Objective To compare definitive therapy with oral β-lactam antibiotics vs fluoroquinolones or TMP-SMX for Enterobacterales bacteremia from a suspected urine source. Design, Setting, and Participants A retrospective cohort study was conducted from January 1, 2007, to September 30, 2015, at 114 Veterans Affairs hospitals among 4089 adults with Escherichia coli, Klebsiella spp, or Proteus spp bacteremia and matching urine culture results. Additional inclusion criteria were receipt of active parenteral antibiotic(s) followed by conversion to an oral antibiotic. Exclusion criteria were previous Enterobacterales bacteremia, urologic abscess, or chronic prostatitis. Data were analyzed from April 15, 2019, to July 26, 2020. Exposures Conversion of therapy to an oral β-lactam antibiotic vs fluoroquinolones or TMP-SMX after 1 to 5 days of parenteral antibiotics. Main Outcomes and Measures The main outcome was a composite of either 30-day all-cause mortality or 30-day recurrent bacteremia. Propensity-based overlap weights were used to adjust for differences between groups. Log binomial regression models were used to estimate adjusted relative risks (aRRs) and adjusted risk differences (aRDs). Results Of the 4089 eligible patients (3731 men [91.2%]; median age, 71 years [interquartile range, 63-81 years]), 955 received an oral β-lactam antibiotic, and 3134 received fluoroquinolones or TMP-SMX. The primary outcome occurred for 42 patients (4.4%) who received β-lactam antibiotics and 94 patients (3.0%) who received fluoroquinolones or TMP-SMX (aRD, 0.99% [95% CI, -0.42% to 2.40%]; aRR, 1.31 [95% CI, 0.87-1.95]). Mortality rates were 3.0% (n = 29) for patients receiving β-lactam antibiotics vs 2.6% (n = 82) for those receiving fluoroquinolones or TMP-SMX (aRD, 0.06% [95% CI, -1.13% to 1.26%]; aRR, 1.02 [95% CI, 0.67-1.56]). Recurrent bacteremia rates were 1.5% (n = 14) among those receiving β-lactam antibiotics vs 0.4% (n = 12) among those receiving fluoroquinolones or TMP-SMX (aRD, 1.03% [95% CI, 0.24%-1.82%]; aRR, 3.43 [95% CI, 0.42-27.90]). Conclusions and Relevance In this cohort study of adults with E coli, Klebsiella spp, or Proteus spp bacteremia from a suspected urine source, the relative risk of recurrent bacteremia was not significantly higher with β-lactam antibiotics compared with fluoroquinolones or TMP-SMX, and the absolute risk and risk difference were small (ie, <3%). No significant difference in mortality was observed. Oral β-lactam antibiotics may be a reasonable step-down treatment option, primarily when alternative options are limited by resistance or adverse effects. Further study is needed because statistical power was limited owing to a low number of recurrent bacteremia events.
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Affiliation(s)
- Jesse D. Sutton
- Department of Pharmacy, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Vanessa W. Stevens
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Nai-Chung N. Chang
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Karim Khader
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Tristan T. Timbrook
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- now at BioFire Diagnostics, Salt Lake City, Utah
| | - Emily S. Spivak
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Lampejo T. Dalbavancin and telavancin in the treatment of infective endocarditis: a literature review. Int J Antimicrob Agents 2020; 56:106072. [PMID: 32629114 DOI: 10.1016/j.ijantimicag.2020.106072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/15/2020] [Accepted: 06/28/2020] [Indexed: 12/20/2022]
Abstract
Glycopeptides have an established role in the management of infective endocarditis, and feature in current treatment guidelines. Newer lipoglycopeptide agents (dalbavancin, telavancin and oritavancin), which are analogues of glycopeptides with structural modifications giving rise to added novel mechanisms of antimicrobial activity, are approved for the treatment of Gram-positive skin and skin structure infections, and also for nosocomial pneumonia (only telavancin has approval for the latter indication). Recent evidence has also emerged to support their use in the treatment of bone and joint infections. This article reviews the current literature on dalbavancin and telavancin in the treatment of infective endocarditis, a condition for which the role of these agents is yet to be established.
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Affiliation(s)
- Temi Lampejo
- Department of Infectious Diseases, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK.
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