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Dequidt T, Bastian S, Nacher M, Breurec S, Carles M, Thiery G, Camous L, Tressieres B, Valette M, Pommier JD. Cefoxitin versus carbapenems as definitive treatment for extended-spectrum β-lactamase-producing Klebsiella pneumoniae bacteremia in intensive care unit: a propensity-matched retrospective analysis. Crit Care 2023; 27:418. [PMID: 37915017 PMCID: PMC10619259 DOI: 10.1186/s13054-023-04712-2] [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: 09/01/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Despite cefoxitin's in vitro resistance to hydrolysis by extended-spectrum beta-lactamases (ESBL), treatment of ESBL-producing Klebsiella pneumoniae (KP) infections with cefoxitin remains controversial. The aim of our study was to compare the clinical efficacy of cefoxitin as definitive antibiotic therapy for patients with ESBL-KP bacteremia in intensive care unit, versus carbapenem therapy. METHODS This retrospective study included all patients with monomicrobial bacteremia hospitalized in intensive care unit between January 2013 and January 2023 at the University Hospital of Guadeloupe. The primary outcome was the 30-day clinical success defined as a composite endpoint: 30-day survival, absence of relapse and no change of antibiotic therapy. Cox regression including a propensity score (PS) and PS-based matched analysis were performed for endpoint analysis. RESULTS A total of 110 patients with bloodstream infections were enrolled. Sixty-three patients (57%) received definitive antibiotic therapy with cefoxitin, while forty-seven (43%) were treated with carbapenems. 30-day clinical success was not significantly different between patients treated with cefoxitin (57%) and carbapenems (53%, p = 0.823). PS-adjusted and PS-matched analysis confirmed these findings. Change of definitive antibiotic therapy was more frequent in the cefoxitin group (17% vs. 0%, p = 0.002). No significant differences were observed for the other secondary endpoints. The acquisition of carbapenem-resistant Pseudomonas aeruginosa was significantly higher in patients receiving carbapenem therapy (5% vs. 23%, p = 0.007). CONCLUSIONS Our results suggest that cefoxitin as definitive antibiotic therapy could be a therapeutic option for some ESBL-KP bacteremia, sparing carbapenems and reducing the selection of carbapenem-resistant Pseudomonas aeruginosa strains.
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Affiliation(s)
- Tanguy Dequidt
- Infectious Diseases Department, University Hospital of Guadeloupe, Pointe-à-Pitre, France.
| | - Sylvaine Bastian
- Laboratory of Clinical Microbiology, University Hospital of Guadeloupe, Pointe-à-Pitre, France
- PCCEI, University of Montpellier, INSERM, EFS, University of Antilles, Pointe-à-Pitre, France
| | - Mathieu Nacher
- Clinical Investigation Center Antilles French Guiana (CIC INSERM 1424), Cayenne Hospital Center, French Guiana, France
| | - Sébastien Breurec
- Laboratory of Clinical Microbiology, University Hospital of Guadeloupe, Pointe-à-Pitre, France
- PCCEI, University of Montpellier, INSERM, EFS, University of Antilles, Pointe-à-Pitre, France
- Transmission, Reservoir and Diversity of Pathogens Unit, Pasteur Institute of Guadeloupe, Pointe-à-Pitre, France
- Faculty of Medicine Hyacinthe Bastaraud, University of Antilles, Pointe-à-Pitre, France
- Centre for Clinical Investigation 1424, INSERM, Pointe-à-Pitre/Les Abymes, France
| | - Michel Carles
- Infectious Diseases Department, University Hospital of Nice, Nice, France
| | - Guillaume Thiery
- Medical Intensive Care Unit, Saint-Etienne University Hospital, Saint-Priest-en-Jarez, France
| | - Laurent Camous
- Intensive Care Unit, University Hospital of Guadeloupe, Pointe-à-Pitre, France
| | - Benoit Tressieres
- Centre for Clinical Investigation 1424, INSERM, Pointe-à-Pitre/Les Abymes, France
| | - Marc Valette
- Intensive Care Unit, University Hospital of Guadeloupe, Pointe-à-Pitre, France
| | - Jean-David Pommier
- Intensive Care Unit, University Hospital of Guadeloupe, Pointe-à-Pitre, France
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Kashihara E, Sada RM, Tsugihashi Y, Obayashi H, Nakamura A, Abe N, Miyake H, Akebo H. Efficacy and Safety of Cefmetazole for Bacteremia Caused by Extended-Spectrum β-Lactamase-Producing Enterobacterales vs Carbapenems: A Retrospective Study. Open Forum Infect Dis 2023; 10:ofad502. [PMID: 37901123 PMCID: PMC10603591 DOI: 10.1093/ofid/ofad502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/06/2023] [Indexed: 10/31/2023] Open
Abstract
Background Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales have become a global concern owing to increased infections, high mortality, and limited antibiotic treatment options. Carbapenems (CPMs) are effective against ESBL-producing Enterobacterales, but their overuse leads to the emergence of multidrug-resistant bacteria. Cefmetazole (CMZ) is effective in vitro; however, its clinical efficacy remains unclear. Methods We retrospectively reviewed patients who were treated with CMZ or CPMs for bacteremia caused by ESBL-producing Enterobacterales between 1 April 2014 and 31 September 2022 at Tenri Hospital. The primary outcome measure was 90-day mortality. We also evaluated resistance genes and sequence types of ESBL-producing Enterobacterales. Results In total, 156 patients were enrolled in this study. Ninety patients (58%) received CMZ therapy. Patients in the CMZ group were significantly older than those in the CPM group (median [IQR], 79 years [71-86] vs 74 years [64-83]; P = .001). The severity of the Pitt bacteremia score of the CMZ group was lower than that in the CPM group (0 [0-2] vs 2 [0-2], P = .042). Six patients (7%) in the CMZ group and 10 (15%) in the CPM group died by day 90 (P = .110). Charlson Comorbidity Index and prevalence of sequence 131 between the groups were statistically insignificant. Conclusions Our findings suggest that CMZ is a well-tolerated alternative to CPM for treating bacteremia caused by ESBL-producing Enterobacterales.
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Affiliation(s)
- Eriko Kashihara
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Ryuichi Minoda Sada
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
- Department of Infection Control, Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Transformative Protection to Infectious Disease, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yukio Tsugihashi
- Medical Home Care Center, Tenri Hospital Shirakawa Branch, Nara, Japan
| | | | - Akihiro Nakamura
- Department of Clinical Laboratory Science, Faculty of Health Care, Tenri University, Tenri, Japan
| | - Noriyuki Abe
- Department of Clinical Microbiology, Clinical Laboratory Medicine, Tenri Hospital, Tenri, Japan
| | - Hirofumi Miyake
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Hiroyuki Akebo
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
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Sakaeda K, Sadahira T, Maruyama Y, Iwata T, Watanabe M, Wada K, Araki M. The Genotypic and Phenotypic Characteristics Contributing to Flomoxef Sensitivity in Clinical Isolates of ESBL-Producing E. coli Strains from Urinary Tract Infections. Antibiotics (Basel) 2023; 12:antibiotics12030522. [PMID: 36978389 PMCID: PMC10044560 DOI: 10.3390/antibiotics12030522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
We carried out a molecular biological analysis of extended-spectrum β-lactamase (ESBL)-producing E. coli strains and their sensitivity to flomoxef (FMOX). Sequence type (ST) analysis by multilocus sequence typing (MLST) and classification of ESBL genotypes by multiplex PCR were performed on ESBL-producing E. coli strains isolated from urine samples collected from patients treated at our institution between 2008 and 2018. These sequences were compared with results for antimicrobial drug susceptibility determined using a micro-liquid dilution method. We also analyzed cases treated with FMOX at our institution to examine its clinical efficacy. Of the 911 E. coli strains identified, 158 (17.3%) were ESBL-producing. Of these, 67.7% (107/158) were strain ST-131 in ST analysis. Nearly all (154/158; 97.5%) were CTX-M genotypes, with M-14 and M-27 predominating. The isolated strains were sensitive to FMOX in drug susceptibility tests. Among the patient samples, 33 cases received FMOX, and of these, 5 had ESBL-producing E. coli. Among these five cases, three received FMOX for surgical prophylaxis as urinary carriers of ESBL-producing E. coli, and postoperative infections were prevented in all three patients. The other two patients received FMOX treatment for urinary tract infections. FMOX treatment was successful for one, and the other was switched to carbapenem. Our results suggest that FMOX has efficacy for perioperative prophylactic administration in urologic surgery involving carriers of ESBL-producing bacteria and for therapeutic administration for urinary tract infections. Use of FMOX avoids over-reliance on carbapenems or β-lactamase inhibitors and thus is an effective antimicrobial countermeasure.
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Affiliation(s)
- Kazuma Sakaeda
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Takuya Sadahira
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan
- Correspondence: ; Tel.: +81-86-231-7287; Fax: +81-86-231-3986
| | - Yuki Maruyama
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Takehiro Iwata
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Masami Watanabe
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Koichiro Wada
- Koichiro Wada Department of Urology, School of Medicine, Shimane University, 89-1, Enya-cho, Izumo 693-8501, Japan
| | - Motoo Araki
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1, Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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Chao CM, Lai CC, Yu WL. Epidemiology of extended-spectrum β-lactamases in Enterobacterales in Taiwan for over two decades. Front Microbiol 2023; 13:1060050. [PMID: 36762100 PMCID: PMC9905819 DOI: 10.3389/fmicb.2022.1060050] [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: 10/02/2022] [Accepted: 12/22/2022] [Indexed: 01/28/2023] Open
Abstract
The emergence of antimicrobial resistance among microorganisms is a serious public health concern, and extended-spectrum β-lactamases (ESBL)-producing Enterobacterales is one of the major concerns among antibiotic-resistant bacteria. Although the prevalence of ESBL in Enterobacterales has been increasing with time, the prevalence of ESBL could differ according to the species, hospital allocation, sources of infections, nosocomial or community acquisitions, and geographic regions. Therefore, we conducted a comprehensive review of the epidemiology of ESBL-producing Enterobacterales in Taiwan. Overall, the rates of ESBL producers are higher in northern regions than in other parts of Taiwan. In addition, the genotypes of ESBL vary according to different Enterobacterales. SHV-type ESBLs (SHV-5 and SHV-12) were the major types of Enterobacter cloacae complex, but Serratia marcescens, Proteus mirabilis, Escherichia coli, and Klebsiella pneumoniae were more likely to possess CTX-M-type ESBLs (CTX-M-3 and CTX-M-14). Moreover, a clonal sequence type of O25b-ST131 has been emerging among urinary or bloodstream E. coli isolates in the community in Taiwan, and this clone was potentially associated with virulence, ESBL (CTX-M-15) production, ciprofloxacin resistance, and mortality. Finally, the evolution of the genetic traits of the ESBL-producing Enterobacterales isolates helps us confirm the interhospital and intrahospital clonal dissemination in several regions of Taiwan. In conclusion, continuous surveillance in the investigation of ESBL production among Enterobacterales is needed to establish its long-term epidemiology.
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Affiliation(s)
- Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Taiwan,Department of Dental Laboratory Technology, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wen-Liang Yu
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan,Department of Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan,*Correspondence: Wen-Liang Yu,
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Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America 2022 Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis 2022; 75:187-212. [PMID: 35439291 PMCID: PMC9890506 DOI: 10.1093/cid/ciac268] [Citation(s) in RCA: 220] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. The initial guidance document on infections caused by extended-spectrum β-lactamase producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa) was published on 17 September 2020. Over the past year, there have been a number of important publications furthering our understanding of the management of ESBL-E, CRE, and DTR-P. aeruginosa infections, prompting a rereview of the literature and this updated guidance document. METHODS A panel of 6 infectious diseases specialists with expertise in managing antimicrobial-resistant infections reviewed, updated, and expanded previously developed questions and recommendations about the treatment of ESBL-E, CRE, and DTR-P. aeruginosa infections. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS Preferred and alternative treatment recommendations are provided with accompanying rationales, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Recommendations apply for both adult and pediatric populations. CONCLUSIONS The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of 24 October 2021. The most current versions of IDSA documents, including dates of publication, are available at www.idsociety.org/practice-guideline/amr-guidance/.
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Affiliation(s)
- Pranita D Tamma
- Correspondence: P. D. Tamma, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA ()
| | - Samuel L Aitken
- Department of Pharmacy, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Robert A Bonomo
- Medical Service and Center for Antimicrobial Resistance and Epidemiology, Louis Stokes Cleveland Veterans Affairs Medical Center, University Hospitals Cleveland Medical Center and Departments of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy J Mathers
- Departments of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Akine D, Sasahara T, Kiga K, Ae R, Kosami K, Yoshimura A, Kubota Y, Sasaki K, Kimura Y, Ogawa M, Watanabe S, Morisawa Y, Cui L. Distribution of Extended-Spectrum β-Lactamase Genes and Antimicrobial Susceptibility among Residents in Geriatric Long-Term Care Facilities in Japan. Antibiotics (Basel) 2021; 11:36. [PMID: 35052913 PMCID: PMC8773109 DOI: 10.3390/antibiotics11010036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 12/30/2022] Open
Abstract
A high prevalence of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) may call for monitoring in geriatric long-term care facilities (g-LTCFs). We surveyed the distribution of ESBL-causative gene types and antimicrobial susceptibility in ESBL-PE strains from residents in g-LTCFs, and investigated the association between ESBL-causative gene types and antimicrobial susceptibility. First, we analyzed the types of ESBL-causative genes obtained from 141 ESBL-PE strains collected from the feces of residents in four Japanese g-LTCFs. Next, we determined the minimum inhibitory concentration values for alternative antimicrobial agents against ESBL-PE, including β-lactams and non-β-lactams. Escherichia coli accounted for 96% of the total ESBL-PE strains. Most strains (94%) contained blaCTX-M group genes. The genes most commonly underlying resistance were of the blaCTX-M-9 and blaCTX-M-1 groups. Little difference was found in the distribution of ESBL-causative genes among the facilities; however, antimicrobial susceptibility differed widely among the facilities. No specific difference was found between antimicrobial susceptibility and the number of ESBL-causative genes. Our data showed that ESBL-PEs were susceptible to some antimicrobial agents, but the susceptibility largely differed among facilities. These findings suggest that each g-LTCF may require specific treatment strategies based on their own antibiogram. Investigations into drug resistance should be performed in g-LTCFs as well as acute medical facilities.
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Affiliation(s)
- Dai Akine
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Teppei Sasahara
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Kotaro Kiga
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Koki Kosami
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Akio Yoshimura
- Medical Corporation Sanikukai Nissin Hospital, Hishimachi 3 chome, Kiryu 376-0001, Gunma, Japan;
| | - Yoshinari Kubota
- Nikko Citizen’s Hospital, Kiyotakiarasawamachi 1752-10, Nikko 321-1441, Tochigi, Japan;
| | - Kazumasa Sasaki
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.S.); (Y.K.)
| | - Yumiko Kimura
- Clinical Microbiology Laboratory, Jichi Medical University Hospital, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.S.); (Y.K.)
| | - Masanori Ogawa
- Health Service Center, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan;
| | - Shinya Watanabe
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
| | - Yuji Morisawa
- Division of Clinical Infectious Diseases, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (D.A.); (Y.M.)
| | - Longzhu Cui
- Division of Bacteriology, School of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke 329-0498, Tochigi, Japan; (K.K.); (S.W.); (L.C.)
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Paul M, Carrara E, Retamar P, Tängdén T, Bitterman R, Bonomo RA, de Waele J, Daikos GL, Akova M, Harbarth S, Pulcini C, Garnacho-Montero J, Seme K, Tumbarello M, Lindemann PC, Gandra S, Yu Y, Bassetti M, Mouton JW, Tacconelli E, Baño JR. European Society of clinical microbiology and infectious diseases (ESCMID) guidelines for the treatment of infections caused by Multidrug-resistant Gram-negative bacilli (endorsed by ESICM -European Society of intensive care Medicine). Clin Microbiol Infect 2021; 28:521-547. [PMID: 34923128 DOI: 10.1016/j.cmi.2021.11.025] [Citation(s) in RCA: 379] [Impact Index Per Article: 126.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
SCOPE These ESCMID guidelines address the targeted antibiotic treatment of 3rd generation cephalosporin-resistant Enterobacterales (3GCephRE) and carbapenem-resistant Gram-negative bacteria, focusing on the effectiveness of individual antibiotics and on combination vs. monotherapy. METHODS An expert panel was convened by ESCMID. A systematic review was performed including randomized controlled trials and observational studies, examining different antibiotic treatment regimens for the targeted treatment of infections caused by the 3GCephRE, carbapenem-resistant Enterobacterales (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and carbapenem-resistant Acinetobacter baumanni (CRAB). Treatments were classified as head-to-head comparisons between individual antibiotics and monotherapy vs. combination therapy regimens, including defined monotherapy and combination regimens only. The primary outcome was all-cause mortality, preferably at 30 days and secondary outcomes included clinical failure, microbiological failure, development of resistance, relapse/recurrence, adverse events and length of hospital stay. The last search of all databases was conducted in December 2019, followed by a focused search for relevant studies up until ECCMID 2021. Data were summarized narratively. The certainty of the evidence for each comparison between antibiotics and between monotherapy vs. combination therapy regimens was classified by the GRADE recommendations. The strength of the recommendations for or against treatments was classified as strong or conditional (weak). RECOMMENDATIONS The guideline panel reviewed the evidence per pathogen, preferably per site of infection, critically appraising the existing studies. Many of the comparisons were addressed in small observational studies at high risk of bias only. Notably, there was very little evidence on the effects of the new, recently approved, beta-lactam beta-lactamase inhibitors on infections caused by carbapenem-resistant Gram-negative bacteria. Most recommendations are based on very-low and low certainty evidence. A high value was placed on antibiotic stewardship considerations in all recommendations, searching for carbapenem-sparing options for 3GCephRE and limiting the recommendations of the new antibiotics for severe infections, as defined by the sepsis-3 criteria. Research needs are addressed.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Pilar Retamar
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Robert A Bonomo
- Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Medical Service, Research Service, and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA;; VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, OH, USA
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - George L Daikos
- First Department of Medicine, National and Kapodistrian University of Athens
| | - Murat Akova
- Hacettepe University School of Medicine, Department Of Infectious Diseases, Ankara, Turkey
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Celine Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
| | | | - Katja Seme
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Italy
| | | | - Sumanth Gandra
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China; Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy; Clinica Malattie Infettive, San Martino Policlinico Hospital, Genoa, Italy
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Tübingen, Germany; German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany.
| | - Jesus Rodriguez Baño
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
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Stewart AG, Harris PNA, Chatfield MD, Littleford R, Paterson DL. Ceftolozane-tazobactam versus meropenem for definitive treatment of bloodstream infection due to extended-spectrum beta-lactamase (ESBL) and AmpC-producing Enterobacterales ("MERINO-3"): study protocol for a multicentre, open-label randomised non-inferiority trial. Trials 2021; 22:301. [PMID: 33888139 PMCID: PMC8060904 DOI: 10.1186/s13063-021-05206-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/18/2021] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Extended-spectrum beta-lactamase (ESBL) and AmpC-producing Enterobacterales are common causes of bloodstream infection. ESBL-producing bacteria are typically resistant to third-generation cephalosporins and result in a sizeable economic and public health burden. AmpC-producing Enterobacterales may develop third-generation cephalosporin resistance through enzyme hyper-expression. In no observational study has the outcome of treatment of these infections been surpassed by carbapenems. Widespread use of carbapenems may drive the development of carbapenem-resistant Gram-negative bacilli. METHODS This study will use a multicentre, parallel group open-label non-inferiority trial design comparing ceftolozane-tazobactam and meropenem in adult patients with bloodstream infection caused by ESBL or AmpC-producing Enterobacterales. Trial recruitment will occur in up to 40 sites in six countries (Australia, Singapore, Italy, Spain, Saudi Arabia and Lebanon). The sample size is determined by a predefined quantity of ceftolozane-tazobactam to be supplied by Merck, Sharpe and Dohme (MSD). We anticipate that a trial with 600 patients contributing to the primary outcome analysis would have 80% power to declare non-inferiority with a 5% non-inferiority margin, assuming a 30-day mortality of 5% in both randomised groups. Once randomised, definitive treatment will be for a minimum of 5 days and a maximum of 14 days with the total duration determined by treating clinicians. Data describing demographic information, risk factors, concomitant antibiotics, illness scores, microbiology, multidrug-resistant organism screening, discharge and mortality will be collected. DISCUSSION Participants will have bloodstream infection due to third-generation cephalosporin non-susceptible E. coli and Klebsiella spp. or Enterobacter spp., Citrobacter freundii, Morganella morganii, Providencia spp. or Serratia marcescens. They will be randomised 1:1 to ceftolozane-tazobactam 3 g versus meropenem 1 g, both every 8 h. Secondary outcomes will be a comparison of 14-day all-cause mortality, clinical and microbiological success at day 5, functional bacteraemia score, microbiological relapse, new bloodstream infection, length of hospital stay, serious adverse events, C. difficile infection, multidrug-resistant organism colonisation. The estimated trial completion date is December 2024. TRIAL REGISTRATION The MERINO-3 trial is registered under the US National Institute of Health ClinicalTrials.gov register, reference number: NCT04238390 . Registered on 23 January 2020.
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Affiliation(s)
- Adam G Stewart
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia.
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | - Patrick N A Harris
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia
- Department of Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Mark D Chatfield
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia
| | - Roberta Littleford
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia
| | - David L Paterson
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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In Vitro Efficacy of Flomoxef against Extended-Spectrum Beta-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae Associated with Urinary Tract Infections in Malaysia. Antibiotics (Basel) 2021; 10:antibiotics10020181. [PMID: 33670224 PMCID: PMC7916913 DOI: 10.3390/antibiotics10020181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 01/24/2023] Open
Abstract
The increasing prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae has greatly affected the clinical efficacy of β-lactam antibiotics in the management of urinary tract infections (UTIs). The limited treatment options have resulted in the increased use of carbapenem. However, flomoxef could be a potential carbapenem-sparing strategy for UTIs caused by ESBL-producers. Here, we compared the in vitro susceptibility of UTI-associated ESBL-producers to flomoxef and established β-lactam antibiotics. Fifty Escherichia coli and Klebsiella pneumoniae strains isolated from urine samples were subjected to broth microdilution assay, and the presence of ESBL genes was detected by polymerase chain reactions. High rates of resistance to amoxicillin-clavulanate (76–80%), ticarcillin-clavulanate (58–76%), and piperacillin-tazobactam (48–50%) were observed, indicated by high minimum inhibitory concentration (MIC) values (32 µg/mL to 128 µg/mL) for both species. The ESBL genes blaCTX-M and blaTEM were detected in both E. coli (58% and 54%, respectively) and K. pneumoniae (88% and 74%, respectively), whereas blaSHV was found only in K. pneumoniae (94%). Carbapenems remained as the most effective antibiotics against ESBL-producing E. coli and K. pneumoniae associated with UTIs, followed by flomoxef and cephamycins. In conclusion, flomoxef may be a potential alternative to carbapenem for UTIs caused by ESBL-producers in Malaysia.
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10
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Gudiol C, Cuervo G, Carratalà J. Optimizing therapy of bloodstream infection due to extended-spectrum β-lactamase-producing Enterobacteriaceae. Curr Opin Crit Care 2020; 25:438-448. [PMID: 31369411 DOI: 10.1097/mcc.0000000000000646] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are increasing worldwide. Carbapenems are usually regarded as the antibiotics of choice for the treatment of serious ESBL infections. However, because of the alarming emergence or carbapenem resistance, interest in effective alternatives has emerged. The present review summarizes the findings published on the antibiotics currently available for treatment of patients with an ESBL-E bloodstream infection (BSI). RECENT FINDINGS Meropenem and imipenem are the drugs recommended for treatment of ESBL BSIs in critically ill patients, and in infections with high bacterial loads or elevated β-lactam minimum inhibitory concentrations. Ertapenem should be reserved for patients with less severe presentations, and should be used at high doses. In milder presentations or BSIs from low-risk sources, other carbapenem-sparing alternatives could be considered: cephamycins, fluoroquinolones, and particularly a β-lactam/β-lactam inhibitor combination (particularly piperacillin/tazobactam). Optimized dosing of piperacillin/tazobactam is recommended (high doses and extended infusion). There are few data on the use of the promising newly available drugs (e.g. ceftolozane/tazobactam, ceftazidime/avibactam, cefiderocol, and plazomicin), and it seems reasonable to reserve them as last-resort drugs. SUMMARY Carbapenems should be used in patients with serious infections; alternatives could be used individually, particularly for definitive treatment of patients with milder presentations.
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Affiliation(s)
- Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona.,REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona.,REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona.,REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
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11
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Karaiskos I, Giamarellou H. Carbapenem-Sparing Strategies for ESBL Producers: When and How. Antibiotics (Basel) 2020; 9:E61. [PMID: 32033322 PMCID: PMC7167803 DOI: 10.3390/antibiotics9020061] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/27/2020] [Accepted: 02/03/2020] [Indexed: 11/30/2022] Open
Abstract
Extended spectrum β-lactamase (ESBL)-producing bacteria are prevalent worldwide and correlated with hospital infections, but they have been evolving as an increasing cause of community acquired infections. The spread of ESBL constitutes a major threat for public health, and infections with ESBL-producing organisms have been associated with poor outcomes. Established therapeutic options for severe infections caused by ESBL-producing organisms are considered the carbapenems. However, under the pressure of carbapenem overuse and the emergence of resistance, carbapenem-sparing strategies have been implemented. The administration of carbapenem-sparing antibiotics for the treatment of ESBL infections has yielded conflicting results. Herein, the current available knowledge regarding carbapenem-sparing strategies for ESBL producers is reviewed, and the optimal conditions for the "when and how" of carbapenem-sparing agents is discussed. An important point of the review focuses on piperacillin-tazobactam as the agent arousing the most debate. The most available data regarding non-carbapenem β-lactams (i.e., ceftolozane-tazobactam, ceftazidime-avibactam, temocillin, cephamycins and cefepime) are also thoroughly presented as well as non β-lactams (i.e., aminoglycosides, quinolones, tigecycline, eravacycline and fosfomycin).
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Affiliation(s)
- Ilias Karaiskos
- Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 15123 Athens, Greece;
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12
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Comparative Activities of Ceftazidime-Avibactam and Ceftolozane-Tazobactam against Enterobacteriaceae Isolates Producing Extended-Spectrum β-Lactamases from U.S. Hospitals. Antimicrob Agents Chemother 2019; 63:AAC.00160-19. [PMID: 31085510 DOI: 10.1128/aac.00160-19] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/03/2019] [Indexed: 01/09/2023] Open
Abstract
The activities of ceftazidime-avibactam, ceftolozane-tazobactam, and comparators were evaluated for 733 isolates displaying resistance to broad-spectrum cephalosporins and carrying extended-spectrum β-lactamase (ESBL) genes detected by whole-genome sequencing analysis. Isolates were collected during 2017 in U.S. hospitals. The ESBL producers were 486 Escherichia coli, 190 Klebsiella pneumoniae, and 42 Enterobacter cloacae isolates and isolates from 3 other species. The most common groups of ESBL-encoding genes were bla CTX-M-15-like (n = 491 isolates) and bla CTX-M-15 alone (n = 168) or plus bla OXA-1 (n = 260), followed by bla CTX-M-14-like (n = 162), which included bla CTX-M-27 and bla CTX-M-14 (104 and 51 isolates, respectively), and bla SHV-12 and bla SHV-7 (48 and 22 isolates, respectively). ESBL producers carried other β-lactamases, including 1 E. cloacae harboring bla KPC-3 All ESBL-producing isolates were susceptible to ceftazidime-avibactam, and 90.2/83.9% (CLSI/EUCAST breakpoints) were susceptible to ceftolozane-tazobactam. Tigecycline (98.1/95.8% susceptible) and colistin (99.2%) were comparators that displayed the greatest activity against these isolates. Ceftolozane-tazobactam inhibited 91.4/83.9% of isolates carrying bla CTX-M-15-like and 97.5/95.1% of isolates carrying bla CTX-M-14-like, and its activity was more limited against the 91 isolates carrying bla SHV (66.7/61.1% susceptible). Ceftolozane-tazobactam inhibited 95.5% of the E. coli isolates but only 83.0%, 64.3%, and 80.0% of K. pneumoniae, E. cloacae, and other species harboring ESBL-encoding genes (CLSI breakpoints), respectively. Outer membrane protein sequences for ceftolozane-tazobactam-nonsusceptible isolates did not exhibit significant differences compared to those in genetically related ceftolozane-tazobactam-susceptible isolates. Ceftazidime-avibactam was more active than other agents tested, including ceftolozane-tazobactam, and the activity of this combination was stable regardless of species or ESBL gene carried.
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13
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Araki K, Fukuoka K, Higuchi H, Aizawa Y, Horikoshi Y. Cefmetazole for extended-spectrum β-lactamase-producing Enterobacteriaceae in pediatric pyelonephritis. Pediatr Int 2019; 61:572-577. [PMID: 30908807 DOI: 10.1111/ped.13847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/18/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pyelonephritis caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is an urgent problem in pediatrics. Although carbapenem is the standard therapy for infections caused by ESBL-producing Enterobacteriaceae, some cephamycins, including cefmetazole, are stable against hydrolysis by ESBL. There are few reports, however, on the use of cefmetazole in children. The aim of this study was to evaluate the therapeutic effect of cefmetazole in pediatric pyelonephritis caused by ESBL-producing Enterobacteriaceae. METHODS Children with pyelonephritis caused by ESBL-producing Enterobacteriaceae were enrolled between April 2010 and November 2016 at Tokyo Metropolitan Children's Medical Center. Presence of ESBL was tested for using the disk diffusion method. Medical records were reviewed for a past history of bacterial infection. The outcomes were clinical cure rate at 4 weeks and the duration of therapy in the cefmetazole and non-cefmetazole groups. RESULTS Fifty-five patients met the criteria for pyelonephritis caused by ESBL-producing Enterobacteriaceae. The most common causative organisms were Escherichia coli (n = 51; 92.7%), Klebsiella pneumoniae (n = 3; 5.5%), and K. oxytoca (n = 1; 1.8%). Thirty-six and 19 patients were treated with cefmetazole and with other antibiotics as definitive therapy, respectively. There was no difference in the clinical cure rate (86.1% vs 89.5%; P = 0.72) or duration of therapy (median, 7.0 vs 7.0 days; P = 0.73) between the cefmetazole and non-cefmetazole groups. CONCLUSIONS Cefmetazole was not inferior to the other antibiotics in the treatment of pyelonephritis caused by ESBL-producing Enterobacteriaceae in children. Cefmetazole is a valuable therapeutic alternative to carbapenems for treating pyelonephritis caused by ESBL-producing Enterobacteriaceae.
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Affiliation(s)
- Kotaro Araki
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kahoru Fukuoka
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Higuchi
- Division of Microbiology, Department of Laboratory, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuta Aizawa
- Department of Pediatrics, Niigata University, Niigata City, Japan
| | - Yuho Horikoshi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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14
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Huang C, Shi Q, Zheng B, Ji J, Ying C, Yu X, Wang H, Xiao Y. Simulating moxalactam dosage for extended-spectrum β-lactamase-producing Enterobacteriaceae using blood antimicrobial surveillance network data. Infect Drug Resist 2019; 12:1199-1208. [PMID: 31190908 PMCID: PMC6522843 DOI: 10.2147/idr.s193712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/11/2019] [Indexed: 11/28/2022] Open
Abstract
Objectives: Monte Carlo simulation (MCS) was used to evaluate optimal dosage for cefepime (FEP), moxalactam (MOX), and cefperazone/sulbactam (CFZ/SBT) against extended-spectrum β-lactamase (ESBL) producers isolated from the Blood Bacterial Resistant Investigation Collaborative System. Methods: Minimum inhibitory concentration (MIC) was tested by agar dilution, and ESBL producers were identified by modified Clinical and Laboratory Standards Institute tests. Pharmacokinetic parameters were derived from data on healthy individuals, and probability of target attainment (PTA) and cumulative fraction of response (CFR) %fT >MIC values were estimated by MCS. Results: A total of 2032 Escherichia coli (875 ESBL-producing) and Klebsiella pneumoniae (157 ESBL-producing) strains, and 371 other Enterobacteriaceae strains, were isolated from patients with bloodstream infections (BSIs). MIC90 values for FEP, MOX, and CFZ/SBT against ESBL-producing E. coli and K. pneumoniae were 64/64 mg/L, 2/32 mg/L, and 64/128 mg/L, respectively. Conventional MOX and CFZ/SBT doses failed to reach 90% PTA against isolates with MICs ≥8 mg/L and ≥4 mg/L, respectively. Against ESBL producers, neither FEP nor CFZ/SBT achieved ≥90% CFR, while CFRs for MOX (1 g iv q6h, 2 g iv q12h, and 2 g iv q8h) exceeded 90% against ESBL-producing E. coli. Simulated CFRs for FEP and MOX were similar (>90%) against non-ESBL-producing Enterobacteriaceae, and higher than CFRs for CFZ/SBT. Conclusion: ESBL producers from BSIs were highly susceptible to MOX, and PTA values were generally higher for MOX than FEP or CFZ/SBT for conventional dosing regimens. This large MCS analysis shows that MOX but not FEP or CFZ/SBT can be used empirically to treat BSIs caused by ESBL-producing E. coli strains.
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Affiliation(s)
- Chen Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Department of Respiratory Medicine, Lihuili Hospital, Ningbo Medical Center, Ningbo, People's Republic of China
| | - Qingyi Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jinru Ji
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Chaoqun Ying
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiao Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Hui Wang
- Department of Respiratory Medicine, Lihuili Hospital, Ningbo Medical Center, Ningbo, People's Republic of China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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15
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Current options for the treatment of infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in different groups of patients. Clin Microbiol Infect 2019; 25:932-942. [PMID: 30986558 DOI: 10.1016/j.cmi.2019.03.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/27/2019] [Accepted: 03/31/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are a frequent cause of invasive infections worldwide. Carbapenems are nowadays the most used drugs to treat these infections. However, due to the increasing rates of resistance to these antimicrobials, carbapenem-sparing alternatives are being investigated. OBJECTIVES AND SOURCES The aim of this narrative literature review is to summarize the published information on the currently available antibiotics for the treatment of ESBL-E infections, providing specific information on three subgroups of patients: Group 1, patients with severe infections or infections from high-risk sources or in severely immunocompromised patients; Group 2, patients with non-severe infections from intermediate-risk source; and Group 3, patients with non-severe urinary tract infection. CONTENT AND IMPLICATIONS For patients in Group 1, the current data would support the use of carbapenems. For milder infections, however, particularly urinary tract infections, other non-carbapenem antibiotics can be considered in selected cases, including beta-lactam/beta-lactam inhibitor combinations, cephamycins, temocillin and aminoglycosides. While specific studies should be performed in these situations, individualized decisions may be taken in order to avoid overuse of carbapenems.
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Lee CH, Chen IL, Li CC, Chien CC. Relation between flomoxef minimum inhibitory concentrations and clinical outcomes of patients treated with flomoxef for Enterobacteriaceae bacteremia. Infect Drug Resist 2018; 11:2471-2480. [PMID: 30568470 PMCID: PMC6267728 DOI: 10.2147/idr.s185670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Flomoxef is potentially effective against β-lactamase-producing Enterobacteriaceae because limited clinical data demonstrate its effectiveness against Enterobacteriaceae bloodstream infections (BSIs) based on its minimum inhibitory concentrations (MICs). This study was conducted to determine the optimal breakpoints based on the survival of patients with Enterobacteriaceae BSIs treated with flomoxef. Methods The 30-day crude mortality rate was analyzed among 224 adults who initiated flomoxef monotherapy for Enterobacteriaceae BSIs at a medical center over a 3-year period, according to the flomoxef MICs of the initial isolates. The outcome was evaluated by classification and regression tree modeling and by logistic regression analysis. Results The 30-day crude mortality was approximately two fold greater in patients whose isolates had flomoxef MICs of ≥2 mg/L (54.9% [62/113]) than in those with isolates with MICs of ≤1 mg/L (26.1% [29/111]); the differences were significant in bivariate analysis (P<0.01) and in survival analysis (log-rank test; P<0.001). The classification and regression tree analysis revealed a split between MICs of 1 and 2 mg/L and predicted the same difference in mortality, with a P-value of <0.001. Flomoxef for Enterobacteriaceae BSIs caused by isolates with flomoxef MICs of ≥2 mg/L was an independent predictor of 30-day crude mortality (adjusted OR 3.76, 95% CI 1.94–7.29). Conclusion Patients with Enterobacteriaceae bacteremia who received flomoxef had a lower 30-day crude mortality when the flomoxef MICs of the isolates were ≤1 mg/L than those with MICs ≥2 mg/L.
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Affiliation(s)
- Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan,
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chia-Chin Li
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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In vitro activity of flomoxef against extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in Korea. Diagn Microbiol Infect Dis 2018; 94:88-92. [PMID: 30658867 DOI: 10.1016/j.diagmicrobio.2018.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/18/2018] [Accepted: 11/21/2018] [Indexed: 11/21/2022]
Abstract
To find an alternative regimen for the treatment of extended-spectrum β-lactamase (EBSL)-producing Enterobacteriaceae infections, we examined the in vitro activity of flomoxef against Escherichia coli and Klebsiella pneumoniae having CTX-M-1 group and/or CTX-M-9 group ESBLs. Boronic acid disk methods and polymerase chain reaction amplification were used to detect for ESBL, and AmpC β-lactamase and AmpC β-lactamase co-producers were excluded. Minimum inhibitory concentrations (MICs) were determined for flomoxef by broth microdilution. One hundred seventy-six isolates (E. coli, n = 93 and K. pneumoniae, n = 83) were analyzed for susceptibility test. A total of 94.3% (166/176) of isolates were susceptible to flomoxef (MIC50/MIC90 were 0.5/8 μg/mL); 98.9% of the ESBL-producing E. coli (MIC50/MIC90 were 1/4 μg/mL) and 89.2% of the ESBL-producing K. pneumoniae (MIC50/MIC90 were 0.5/16 μg/mL) were susceptible to flomoxef. Flomoxef has good in vitro activity against ESBL-producing E. coli and K. pneumoniae and could be considered as an alternative for infections caused by these organisms.
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Treatment of Infections Caused by Extended-Spectrum-Beta-Lactamase-, AmpC-, and Carbapenemase-Producing Enterobacteriaceae. Clin Microbiol Rev 2018; 31:31/2/e00079-17. [PMID: 29444952 DOI: 10.1128/cmr.00079-17] [Citation(s) in RCA: 421] [Impact Index Per Article: 70.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Therapy of invasive infections due to multidrug-resistant Enterobacteriaceae (MDR-E) is challenging, and some of the few active drugs are not available in many countries. For extended-spectrum β-lactamase and AmpC producers, carbapenems are the drugs of choice, but alternatives are needed because the rate of carbapenem resistance is rising. Potential active drugs include classic and newer β-lactam-β-lactamase inhibitor combinations, cephamycins, temocillin, aminoglycosides, tigecycline, fosfomycin, and, rarely, fluoroquinolones or trimethoprim-sulfamethoxazole. These drugs might be considered in some specific situations. AmpC producers are resistant to cephamycins, but cefepime is an option. In the case of carbapenemase-producing Enterobacteriaceae (CPE), only some "second-line" drugs, such as polymyxins, tigecycline, aminoglycosides, and fosfomycin, may be active; double carbapenems can also be considered in specific situations. Combination therapy is associated with better outcomes for high-risk patients, such as those in septic shock or with pneumonia. Ceftazidime-avibactam was recently approved and is active against KPC and OXA-48 producers; the available experience is scarce but promising, although development of resistance is a concern. New drugs active against some CPE isolates are in different stages of development, including meropenem-vaborbactam, imipenem-relebactam, plazomicin, cefiderocol, eravacycline, and aztreonam-avibactam. Overall, therapy of MDR-E infection must be individualized according to the susceptibility profile, type, and severity of infection and the features of the patient.
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Tamma PD, Rodriguez-Bano J. The Use of Noncarbapenem β-Lactams for the Treatment of Extended-Spectrum β-Lactamase Infections. Clin Infect Dis 2017; 64:972-980. [PMID: 28362938 DOI: 10.1093/cid/cix034] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/14/2017] [Indexed: 12/17/2022] Open
Abstract
The continued rise in infections caused by extended-spectrum β-lactamase (ESBL)-producing pathogens is recognized globally as one of the most pressing concerns facing the healthcare community. Carbapenems are widely regarded as the antibiotics of choice for the treatment of ESBL-producing infections, even when in vitro activity to other β-lactams has been demonstrated. However, indiscriminant carbapenem use is not without consequence, and carbapenem overuse has contributed to the emergence of carbapenem-resistant Enterobacteriaceae. The use of non-carbapenem β-lactams for the treatment of ESBL infections has yielded conflicting results. In this review, we discuss the available data for the use of cephamycins, cefepime, piperacillin-tazobactam, ceftolozane-tazobactam, and ceftazidime-avibactam for the treatment of ESBL infections.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Pediatric Infectious Diseases, Baltimore, Maryland
| | - Jesus Rodriguez-Bano
- Infectious Diseases and Microbiology, Instituto de Biomedicina de Sevilla/Hospital Universitario Virgen Macarena/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, Spain
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Chastain DB, White BP, Cretella DA, Bland CM. Is It Time to Rethink the Notion of Carbapenem-Sparing Therapy Against Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae Bloodstream Infections? A Critical Review. Ann Pharmacother 2017; 52:484-492. [PMID: 29239220 DOI: 10.1177/1060028017748943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To present systematic recommendations for carbapenem-sparing therapy against extended-spectrum β-lactamases (ESBLs) Enterobacteriaceae bloodstream infections (BSIs) derived from a critical review of clinical data. DATA SOURCES A systematic literature search using PubMed and MEDLINE databases (January 1, 2012, to June 30, 2017) was performed using key MESH terms: ESBL or extended-spectrum β-lactamases and bacteremia or bloodstream infection with piperacillin/tazobactam, ciprofloxacin, levofloxacin, cefepime, cephamycins, carbapenem, doripenem, meropenem, and ertapenem. References within articles of interest were also evaluated. STUDY SELECTION AND DATA EXTRACTION All English language trials were considered, and results were limited to clinical efficacy trials. Articles were screened by title and abstract for inclusion. DATA SYNTHESIS Studies comparing noncarbapenem versus carbapenem therapy for ESBL BSIs were critically analyzed to identify heterogeneity among studies. Data abstracted included empirical or definitive therapy, patient population, dosing, source of infection and severity, infectious etiology, and outcome. CONCLUSIONS Completely sparing carbapenem therapy cannot be justified among patients with ESBL BSIs. Determining the source of infection is critical to identify patients for whom carbapenem-sparing therapy is appropriate.
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Affiliation(s)
| | - Bryan P White
- 2 Oklahoma University Medical Center, Oklahoma City, OK, USA
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Cubero M, Grau I, Tubau F, Pallarés R, Domínguez MÁ, Liñares J, Ardanuy C. Molecular Epidemiology of Klebsiella pneumoniae Strains Causing Bloodstream Infections in Adults. Microb Drug Resist 2017; 24:949-957. [PMID: 29227744 DOI: 10.1089/mdr.2017.0107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Molecular epidemiology of Klebsiella pneumoniae bacteremic strains allows for a better understanding of preventive and therapeutic strategies. Clinical and microbiological characteristics of 348 K. pneumoniae bacteremia cases (2007-2009) were retrospectively characterized by multilocus sequence typing and extended-spectrum beta-lactamases (ESBL) production. Overall, 223 (64.08%) cases were nosocomial (NA), 58 (16.67%) healthcare associated, and 67 (19.25%) community acquired. The main infection origins were urinary tract (16.6%, 50.0%, and 43.3%), biliary tract (10.8%, 24.2%, and 31.3%), and catheter-related infection (39.9%, 5.2%, and 0%). The 30-day mortality rate was around 20%. The rates of resistance were around 45% the highest being among NA cases, and ESBL production was detected in 7.2% of cases. A total of 161 different sequence types were grouped into 13 clonal sets by e-burst analysis. No relationship could be established between clonal sets and the origin of infection or the healthcare-related settings. The high genetic variability among the isolates suggests their intrapatient endogenous origin.
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Affiliation(s)
- Meritxell Cubero
- 1 Department of Microbiology, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , University of Barcelona, Barcelona, Spain .,2 Research Network for Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
| | - Imma Grau
- 2 Research Network for Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain .,3 Infectious Diseases Department, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Fe Tubau
- 1 Department of Microbiology, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , University of Barcelona, Barcelona, Spain .,2 Research Network for Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
| | - Román Pallarés
- 2 Research Network for Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain .,3 Infectious Diseases Department, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), University of Barcelona , Barcelona, Spain
| | - M Ángeles Domínguez
- 1 Department of Microbiology, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , University of Barcelona, Barcelona, Spain .,4 Spanish Network for Research in Infectious Diseases (REIPI RD06/0008) , Barcelona, Spain
| | - Josefina Liñares
- 1 Department of Microbiology, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , University of Barcelona, Barcelona, Spain .,2 Research Network for Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
| | - Carmen Ardanuy
- 1 Department of Microbiology, Hospital Universitari de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , University of Barcelona, Barcelona, Spain .,2 Research Network for Respiratory Diseases (CIBERES), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
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22
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Alevizakos M, Karanika S, Detsis M, Mylonakis E. Colonisation with extended-spectrum β-lactamase-producing Enterobacteriaceae and risk for infection among patients with solid or haematological malignancy: a systematic review and meta-analysis. Int J Antimicrob Agents 2016; 48:647-654. [PMID: 27746102 DOI: 10.1016/j.ijantimicag.2016.08.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/11/2016] [Accepted: 08/20/2016] [Indexed: 01/05/2023]
Abstract
Cancer patients are vulnerable to infections, including those with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), and most of these infections are associated with colonisation of the gastrointestinal tract. The aim of this study was to estimate the prevalence of gastrointestinal colonisation with ESBL-PE cancer populations and to determine the risk for subsequent bloodstream infection (BSI) with these pathogens. PubMed and EMBASE databases were searched from 1 January 1991 to 1 March 2016 to identify studies regarding ESBL-PE colonisation among patients with malignancies. Ten studies (out of 561 non-duplicate articles) were included, providing data on 2211 patients. The pooled prevalence of ESBL-PE colonisation was 19% [95% confidence interval (CI) 8-32%]. Stratifying per region, the pooled prevalence in Europe was 15% (95% CI 10-21%), whereas in Asia the pooled prevalence was 31% (95% CI 4-69%). In addition, the pooled prevalence was 15% (95% CI 7-24%) among patients with haematological malignancy, whereas no studies were identified that included solely patients with solid tumours. Notably, cancer patients with ESBL-PE colonisation were 12.98 times (95% CI 3.91-43.06) more likely to develop a BSI with ESBL-PE during their hospitalisation compared with non-colonised patients. We found that, overall, one in five patients with cancer is colonised with ESBL-PE and the incidence can be as high as one in three in Asia. This is important because colonisation was associated with an almost 13 times higher risk for developing BSI with ESBL-PE. Screening measures should be evaluated to identify their clinical benefit in patients with malignancy.
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Affiliation(s)
- Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Styliani Karanika
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Marios Detsis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA.
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23
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Yu WL, Lee MF, Chen CC, Tang HJ, Ho CH, Chuang YC. Impacts of Hypervirulence Determinants on Clinical Features and Outcomes of Bacteremia Caused by Extended-Spectrum β-Lactamase-Producing Klebsiella pneumoniae. Microb Drug Resist 2016; 23:376-383. [PMID: 27380450 DOI: 10.1089/mdr.2016.0018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We investigated the implications of hypervirulence determinants on clinical features of 48 adult patients with bacteremia caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae. Isolates in the hypervirulence group included any of the following virulence determinants: K1/K2 capsule serotypes, hypermucoviscosity phenotype, rmpA gene, or rmpA2 gene. Nonhypervirulence group isolates were negative for all of the above virulence factors. In this study, all isolates used were non-K1/K2 strains. Statistically significant differences were observed in clinical features of patients between the two groups. The hypervirulent isolates (n = 19), including 11 isolates with the hypermucoviscosity phenotype, 15 with the rmpA gene, and 16 with the rmpA2 gene, were more commonly recovered from diabetic patients and mainly manifested as secondary bacteremia (such as pneumonia, urinary tract infections, or other localized infections). The nonhypervirulent isolates (n = 29) were more commonly recovered from patients after prolonged hospital stays (>30 days) and mostly manifested as primary bacteremia. The overall in-hospital mortality was 56.3%. Hazard ratio (HR) analysis revealed the following positive predictors for mortality: nosocomial infection, stay in an intensive care unit, no removal of the central venous catheter, Charlson comorbidity score, and APACHE II score (≧15). The negative predictors were initial appropriate antibiotic therapy (HR 0.42) and urinary tract infection (HR 0.19). Charlson score was an independent confounder based on multivariate analysis (HR 1.43, 95% confidence interval 1.04-1.99). In conclusion, hypervirulence determinants played a role in causing secondary infections in diabetic patients; however, the presence of morbidity cofactors could themselves influence mortality, despite the absence of hypervirulence determinants.
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Affiliation(s)
- Wen-Liang Yu
- 1 Department of Intensive Care Medicine, Chi Mei Medical Center , Tainan City, Taiwan .,2 Department of Medicine, Taipei Medical University , Taipei City, Taiwan
| | - Mei-Feng Lee
- 3 Department of Medical Research, Chi Mei Medical Center , Tainan City, Taiwan
| | - Chi-Chung Chen
- 3 Department of Medical Research, Chi Mei Medical Center , Tainan City, Taiwan
| | - Hung-Jen Tang
- 4 Department of Internal Medicine, Chi Mei Medical Center , Tainan City, Taiwan .,5 Department of Health and Nutrition, Chia Nan University of Pharmacy and Science , Tainan City, Taiwan
| | - Chung-Han Ho
- 3 Department of Medical Research, Chi Mei Medical Center , Tainan City, Taiwan
| | - Yin-Ching Chuang
- 3 Department of Medical Research, Chi Mei Medical Center , Tainan City, Taiwan .,6 Department of Internal Medicine, Chi Mei Medical Center-Liou Ying , Tainan City, Taiwan
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Lee CH, Su LH, Chen FJ, Tang YF, Li CC, Chien CC, Liu JW. Comparative effectiveness of flomoxef versus carbapenems in the treatment of bacteraemia due to extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella pneumoniae with emphasis on minimum inhibitory concentration of flomoxef: a retrospective study. Int J Antimicrob Agents 2015; 46:610-5. [PMID: 26387064 DOI: 10.1016/j.ijantimicag.2015.07.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/26/2015] [Accepted: 07/20/2015] [Indexed: 11/26/2022]
Abstract
This study compared treatment outcomes of adult patients with bacteraemia due to extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella pneumoniae (ESBL-EK) receiving flomoxef versus those receiving a carbapenem as definitive therapy. In propensity score matching (PSM) analysis, case patients receiving flomoxef shown to be active in vitro against ESBL-EK were matched with controls who received a carbapenem. The primary endpoint was 30-day crude mortality. The flomoxef group had statistically significantly higher sepsis-related mortality (27.3% vs. 10.5%) and 30-day mortality (28.8% vs. 12.8%) than the carbapenem group. Of the bacteraemic episodes caused by isolates with a MICflomoxef of ≤1 mg/L, sepsis-related mortality rates were similar between the two treatment groups (8.7% vs. 6.4%; P=0.73). The sepsis-related mortality rate of the flomoxef group increased to 29.6% and 50.0% of episodes caused by isolates with a MICflomoxef of 2-4 mg/L and 8 mg/L, respectively, which was significantly higher than the carbapenem group (12.3%). In the PSM analysis of 86 case-control pairs infected with strains with a MICflomoxef of 2-8 mg/L, case patients had a significantly higher 30-day mortality rate (38.4% vs. 18.6%). Multivariate regression analysis revealed that flomoxef therapy for isolates with a MICflomoxef of 2-8 mg/L, concurrent pneumonia or urosepsis, and a Pitt bacteraemia score ≥4 were independently associated with 30-day mortality. Definitive flomoxef therapy appears to be inferior to carbapenems in treating ESBL-EK bacteraemia, particularly for isolates with a MICflomoxef of 2-8 mg/L, even though the currently suggested MIC breakpoint of flomoxef is ≤8 mg/L.
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Affiliation(s)
- Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan; Chang Gung University, College of Medicine, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan.
| | - Lin-Hui Su
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, 5 Fu-Hsin Street, Kweishan, Taoyuan 333, Taiwan; Chang Gung University College of Medicine, 259 Wenhua 1st Road, Kweishan, Taoyuan 333, Taiwan
| | - Fang-Ju Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Ya-Feng Tang
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Chia-Chin Li
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Jien-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan; Chang Gung University, College of Medicine, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
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25
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Matsumura Y, Yamamoto M, Nagao M, Komori T, Fujita N, Hayashi A, Shimizu T, Watanabe H, Doi S, Tanaka M, Takakura S, Ichiyama S. Multicenter retrospective study of cefmetazole and flomoxef for treatment of extended-spectrum-β-lactamase-producing Escherichia coli bacteremia. Antimicrob Agents Chemother 2015; 59:5107-13. [PMID: 26100708 PMCID: PMC4538479 DOI: 10.1128/aac.00701-15] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/17/2015] [Indexed: 01/23/2023] Open
Abstract
The efficacy of cefmetazole and flomoxef (CF) for the treatment of patients with extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) bacteremia (ESBL-CF group) was compared with that of carbapenem treatment for ESBL-EC patients (ESBL-carbapenem group) and with that of CF treatment in patients with non-ESBL-EC bacteremia (non-ESBL-CF group). Adult patients treated for E. coli bacteremia in four hospitals were retrospectively evaluated. The 30-day mortality rates in patients belonging to the ESBL-CF, ESBL-carbapenem, and non-ESBL-CF groups were compared as 2 (empirical and definitive therapy) cohorts. The adjusted hazard ratios (aHRs) for mortality were calculated using Cox regression models with weighting according to the inverse probability of propensity scores for receiving CF or carbapenem treatment. The empirical-therapy cohort included 104 patients (ESBL-CF, 26; ESBL-carbapenem, 45; non-ESBL-CF, 33), and the definitive-therapy cohort included 133 patients (ESBL-CF, 59; ESBL-carbapenem, 54; non-ESBL-CF, 20). The crude 30-day mortality rates for patients in the ESBL-CF, ESBL-carbapenem, and non-ESBL-CF groups were, respectively, 7.7%, 8.9%, and 3.0% in the empirical-therapy cohort and 5.1%, 9.3%, and 5.0% in the definitve-therapy cohort. In patients without hematological malignancy and neutropenia, CF treatment for ESBL-EC patients was not associated with mortality compared with carbapenem treatment (empirical-therapy cohort: aHR, 0.87; 95% confidence interval [CI], 0.11 to 6.52; definitive therapy cohort: aHR, 1.04; CI, 0.24 to 4.49). CF therapy may represent an effective alternative to carbapenem treatment for patients with ESBL-EC bacteremia for empirical and definitive therapy in adult patients who do not have hematological malignancy and neutropenia.
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Affiliation(s)
- Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Yamamoto
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miki Nagao
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshiaki Komori
- Department of Infection Control and Clinical Laboratory, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Fujita
- Department of Infection Control and Clinical Laboratory, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akihiko Hayashi
- Department of Clinical Laboratory, Kyoto City Hospital, Kyoto, Japan
| | - Tsunehiro Shimizu
- Department of Infectious Diseases, Kyoto City Hospital, Kyoto, Japan
| | - Harumi Watanabe
- Department of Clinical Laboratory, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Shoichi Doi
- Division of Hematology, Department of Internal Medicine, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Michio Tanaka
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shunji Takakura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Ichiyama
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Rodríguez-Baño J, Cisneros JM, Cobos-Trigueros N, Fresco G, Navarro-San Francisco C, Gudiol C, Horcajada JP, López-Cerero L, Martínez JA, Molina J, Montero M, Paño-Pardo JR, Pascual A, Peña C, Pintado V, Retamar P, Tomás M, Borges-Sa M, Garnacho-Montero J, Bou G. Diagnosis and antimicrobial treatment of invasive infections due to multidrug-resistant Enterobacteriaceae. Guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology. Enferm Infecc Microbiol Clin 2015; 33:337.e1-337.e21. [DOI: 10.1016/j.eimc.2014.11.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 12/21/2022]
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Bettiol E, Rottier WC, Del Toro MD, Harbarth S, Bonten MJ, Rodríguez-Baño J. Improved treatment of multidrug-resistant bacterial infections: utility of clinical studies. Future Microbiol 2015; 9:757-71. [PMID: 25046523 DOI: 10.2217/fmb.14.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In a time of increasing antibacterial resistance and limited availability of new antibiotics, clinical studies are much needed to assess treatment options against multidrug-resistant organisms (MDROs). In this review, we describe the clinical challenge caused by MDROs and present recent evidence on how clinical studies may generate quality data to improve antibiotic treatment of MDRO infections. To this aim, we critically assess the current status, gaps and challenges associated with observational and interventional studies performed to assess MDRO treatment options. We address why observational studies are useful, which treatment options for MDRO have been explored by observational studies and how to improve quality and usefulness of observational studies. Furthermore, the utility of clinical pharmacokinetic/pharmacodynamic studies for improving MDRO treatment is described. Finally, we discuss interventional study designs, end points and margins, as well as ethical, logistic and statistical challenges, and current regulatory changes proposed to foster the development of new antibiotics.
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Affiliation(s)
- Esther Bettiol
- Infection Control Program, University of Geneva Hospitals & Faculty of Medicine, Geneva, Switzerland
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28
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Yang CC, Wu CH, Lee CT, Liu HT, Chen JB, Chiu CH, Chen CH, Chuang FR. Nosocomial extended-spectrum beta-lactamase-producing Klebsiella pneumoniae bacteremia in hemodialysis patients and the implications for antibiotic therapy. Int J Infect Dis 2014; 28:3-7. [PMID: 25200093 DOI: 10.1016/j.ijid.2014.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/02/2014] [Accepted: 07/08/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In the face of increasing treatment options for extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) hemodialysis (HD) access-related bacteremia, the difference in clinical effectiveness between ertapenem and flomoxef remains unclear. We conducted this retrospective study to determine their efficacies and treatment outcomes. METHODS Patients on maintenance HD with fistula-, graft-, or catheter-related ESBL-Kp bacteremia were enrolled. Data related to clinical features and antibiotic treatments were collected. Outcome was determined by mortality resulting from bacteremia during the 14-day period after the collection of the first positive blood culture for flomoxef-susceptible ESBL-Kp. RESULTS The 64 patients studied had severe septicemia as determined by the Pitt bacteremia score; 50% (32/64) were in the intensive care unit (ICU) at the time of bacteremia. Old age (>65 years; 57.8%), malnutrition (albumin<3.5g/dl; 92.2%), a history of severe illnesses (defined by shock, intubation, or ICU stay; 82.5%), and prolonged hospitalization prior to the onset of bacteremia (>30 days; 75%) were also highly prevalent. The study population comprised nine fistula-, 10 graft-, and 45 HD catheter-related bacteremia cases, and the mortality rate was high (38/64, 59.4%). The mortality rate was significantly higher in the flomoxef treatment group than in the ertapenem treatment group (22/30, 73% vs. 16/34, 47%, p<0.05). Among patients with catheter-related bacteremia, multivariate analyses revealed that flomoxef use (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.34-35.17) and Pitt bacteremia score (OR 4.37, 95% CI 1.28-5.26) were independently associated with mortality. CONCLUSIONS In accordance with our previous study, our results have demonstrated the inferiority of flomoxef to carbapenems in the treatment of HD access-related ESBL-Kp bacteremia and provide an insight into the possibility of using ertapenem rather than flomoxef as an initial or de-escalating therapy for infections caused by ESBL-producing bacteria.
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Affiliation(s)
- Chih-Chao Yang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan
| | - Chien-Hsing Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan
| | - Chien-Te Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan
| | - Han-Tsung Liu
- Division of Trauma and Emergency Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jin-Bor Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan
| | - Chien-Hua Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan
| | - Chih-Hung Chen
- Division of General Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Feng-Rong Chuang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan.
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