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Bryson AL, Bhalodi A, Liesman RM, Mathers AJ. Cefazolin as a predictor of urinary cephalosporin activity in indicated Enterobacterales. J Clin Microbiol 2024; 62:e0078821. [PMID: 38457194 PMCID: PMC11005412 DOI: 10.1128/jcm.00788-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
Traditionally, cephalothin susceptibility results were used to predict the susceptibility of additional cephalosporins; however, in 2013-2014, the Clinical and Laboratory Standards Institute (CLSI) revisited this practice and determined that cefazolin is a more accurate proxy than cephalothin for uncomplicated urinary tract infections (uUTIs). Therefore, a cefazolin surrogacy breakpoint was established to predict the susceptibility of seven oral cephalosporins for Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis in the context of uUTIs. Clinical microbiology laboratories face several operational challenges when implementing the cefazolin surrogacy breakpoint, which may lead to confusion for the best path forward. Here, we review the historical context and data behind the surrogacy breakpoints, review PK/PD profiles for oral cephalosporins, discuss challenges in deploying the breakpoint, and highlight the limited clinical outcome data in this space.
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Affiliation(s)
- Alexandra L. Bryson
- Department of Pathology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Amira Bhalodi
- Scientific and Medical Affairs Consulting, Newton, Pennsylvania, USA
| | - Rachael M. Liesman
- Department of Pathology and Laboratory Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy J. Mathers
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
- Clinical Microbiology Laboratory, Department of Pathology, University of Virginia Health, Charlottesville, Virginia, USA
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Stewart AG, Bauer MJ, Butkiewicz D, Hinton A, Henderson A, Harris PN, Paterson DL. In vitro activity of oral third-generation cephalosporins plus clavulanate against ESBL-producing Enterobacterales isolates from the MERINO trial. Int J Antimicrob Agents 2023:106858. [PMID: 37211261 DOI: 10.1016/j.ijantimicag.2023.106858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
Extended-spectrum-beta-lactamase (ESBL)-producing Enterobacterales as a cause of community-acquired uncomplicated urinary tract infection (UTI) is on the rise. Currently, minimal oral treatment options exist. New combinations of existing oral third generation cephalosporins paired with clavulanate may overcome resistance mechanisms seen in these emerging uropathogens. Ceftriaxone-resistant E. coli and Klebsiella pneumoniae containing CTX-M-type ESBLs or AmpC, in addition to narrow-spectrum OXA and SHV enzymes, were selected from blood culture isolates obtained from the MERINO trial. Minimum inhibitory concentration (MIC) values of third generation cephalosporins (cefpodoxime, ceftibuten, cefixime, cefdinir) both with and without clavulanate were determined. One hundred and one isolates were used with ESBL, AmpC and narrow-spectrum OXA genes (e.g. OXA-1, OXA-10) present in 84, 15 and 35 isolates, respectively. Susceptibility to oral third generation cephalosporins alone was very poor. Addition of 2 mg/L clavulanate lowered the MIC50 values (cefpodoxime MIC50 2 mg/L, ceftibuten MIC50 2 mg/L, cefixime MIC50 2 mg/L, cefdinir MIC50 4 mg/L) and restored susceptibility (33%, 49%, 40%, and 21% susceptible, respectively) in a substantial number of isolates. This finding was less pronounced in isolates co-harbouring AmpC. In vitro activity of these new combinations may be limited in real world Enterobacterales isolates co-harbouring multiple antimicrobial resistance genes. Pharmacokinetic/pharmacodynamic data would be useful in further evaluating their activity.
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Affiliation(s)
- Adam G Stewart
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia; Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Michelle J Bauer
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | - Dominika Butkiewicz
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | - Alexandra Hinton
- Centre for Superbug Solutions, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Andrew Henderson
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia; Infection Management Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Patrick Na Harris
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia; Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - David L Paterson
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia; ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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