Ceftazidime-Avibactam for the Treatment of Carbapenem-Resistant Klebsiella pneumoniae Infections in Patients With Liver Cirrhosis

The efficacy and safety of ceftazidime/avibactam or polymyxin B based regimens for carbapenem-resistant Pseudomonas aeruginosa infection: a multicenter real-world and propensity score-matched study

Introduction

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) infections pose a critical clinical challenge. Although ceftazidime/avibactam (CAZ/AVI) and polymyxin B (PMB) are frontline therapies, their comparative effectiveness in terms of 30-day survival, renal safety profiles, and clinical success rates remains poorly characterized. To address this knowledge gap, a multicenter real-world study was conducted.

Methods

CRPA-infected patients treated with PMB or CAZ/AVI-based regimens were enrolled from five hospitals between January 1, 2021, to July 31, 2023. Propensity score matching (PSM) and binary logistic regression analysis were performed to evaluate efficacy and acute renal injury (AKI) occurrence, and a multivariable COX proportional hazards regression of the 30-day all-cause mortality was performed.

Results

170 CRPA-infected patients were enrolled, among whom 124 (72.9%) had difficult-to-treat resistant P. aeruginosa (DTR-PA) infections and 77 (45.3%) received CAZ/AVI-based regimens. After 1:1 PSM, the results demonstrated that the CRPA clearance rate was significantly higher in the CAZ/AVI group compared to the PMB group (61.0% vs. 24.4%, p = 0.001); however, no significant differences were observed in clinical success rates (55.6% vs. 44.4%), incidence of AKI (26.8% vs. 39.0%), or 30-day all-cause mortality (7.3% vs. 12.2%) between the two groups (all p > 0.05). Compared with the PMB-based regimens, CAZ/AVI-based regimens were significantly associated with CRPA clearance success (OR 0.185, 95%CI 0.061-0.564, p < 0.001); additionally, multi-site infection (OR 0.295, 95%CI 0.097-0.899, p = 0.032) and the number of combined anti-PA antibiotics (OR 0.435, 95%CI 0.213-0.888, p = 0.022) were associated with enhanced CRPA clearance. The occurrence of AKI in patients with CRPA infection was associated with underlying diseases, including sepsis/septic shock (OR 3.405, 95%CI 1.007-11.520, p = 0.049), and diabetes mellitus (OR 3.600, 95%CI 1.018-12.733, p = 0.047). In addition, other CREs infection (HR 40.849, 95%CI 3.323-502.170, p = 0.004), APACHE II score (HR 1.072, 95%CI 1.032-1.114, p < 0.001) were found to be independent predictors of 30-day all-cause mortality.

Conclusion

In conclusion, CAZ/AVI-based regimens demonstrated superior efficacy in clearing CRPA compared to PMB-based regimens. Furthermore, several factors associated with AKI and mortality in CRPA-infected patients were identified, highlighting the need for further research to optimize treatment strategies.

Comparing ceftazidime/avibactam and polymyxin B for treating carbapenem-resistant organisms infections: A propensity score-matched retrospective cohort study

BACKGROUND AND AIM

There are limited comparative studies of ceftazidime/avibactam (CAZ/AVI) vs. polymyxin B (PMB) for carbapenem-resistant organisms (CRO) infections. The aim of this study was to compare the efficacy and safety of CAZ/AVI and PMB in treating CRO infections.

METHODS

This single-centre, retrospective cohort study with propensity score-matching (PSM) involved adult patients with CRO infections. Patients who received the CAZ/AVI-based regimen were included in the cohort group; those prescribed with the PMB-based regimen were included in the control group. The primary outcome was 28-day all-cause mortality.

RESULTS

Among 298 eligible patients, 96 patients in each group were included in the PSM cohort. The CAZ/AVI group showed no improvement in 28-day or 14-day all-cause mortality, nor in 14-day clinical response, compared to the PMB group. However, the CAZ/AVI-based regimen was associated with higher 14-day clinical response rates than the PMB-based regimen in subgroups with carbapenem-resistant Pseudomonas aeruginosa (CRPA) infections and monotherapy. The CAZ/AVI group achieved greater CRO eradication than the PMB group (crude odds ratio [OR], 1.658; 95% confidence interval [CI], 1.108-2.480; P = 0.014; adjusted OR, 1.718; 95% CI, 1.055-2.798; P = 0.030). This advantage in CRO eradication with CAZ/AVI was consistent in most subgroups, including septic shock, bloodstream infection and lower respiratory tract infection. The CAZ/AVI and PMB groups had comparable nephrotoxicity (crude OR, 0.577; 95% CI, 0.306-1.089; P = 0.090; adjusted OR, 0.741; 95% CI, 0.361-1.521; P = 0.414).

CONCLUSION

CAZ/AVI-based and PMB-based regimens demonstrated similar clinical efficacy and nephrotoxicity in treating CRO infections. However, CAZ/AVI was superior to PMB in CRO eradication and treating CRPA infections. CAZ/AVI monotherapy was more effective than PMB monotherapy for CRO infections.

TRIAL REGISTRATION

ChiCTR2300078790 prospectively registered on 19 Dec 2023 (https://www.chictr.org.cn).

Revisiting septic shock in cirrhosis: a call for personalized management

INTRODUCTION

Patients with cirrhosis are known to be prone to infections. Infections can trigger organ failures and decompensations in cirrhosis. Septic shock can increase mortality by fourfold and cause hemodynamic imbalances, adding to the already hyperdynamic circulation. Management of septic shock in cirrhosis can be tricky due to this complex interplay of altered hemodynamics, immune function, and coagulation.

AREAS COVERED

In this review, we explore the pathophysiological basis, screening, monitoring and management of septic shock in cirrhosis. We also explore novel biomarkers, the growing challenge of multidrug-resistant pathogens and novel and adjunctive therapies. Finally, we propose an algorithm for the management of septic shock in cirrhosis. We conducted a comprehensive search of electronic databases such as PubMed, Web of Science, and Cochrane Library using the keywords and MeSH terms like 'septic shock,' 'cirrhosis,' 'liver disease,' 'sepsis' among others. The search was restricted to peer-reviewed articles in English.

EXPERT OPINION

The difficulties in managing septic shock in cirrhosis are discussed, emphasizing personalized approaches over protocol-driven care. Fluid and vasopressor management, antibiotic timing and selection, the role of adjunctive therapies, the importance of lactate clearance, gut failure, and the need for further research in this population are highlighted.

Ceftazidime-avibactam: Combination therapy versus monotherapy in the challenge of pneumonia caused by carbapenem-resistant Klebsiella pneumoniae

This research focused on evaluating the clinical results of patients suffering from pneumonia caused by carbapenem-resistant Klebsiella pneumoniae (CRKP), who received treatment with either ceftazidime-avibactam (CZA) alone or in combination with other antibiotics. From January 2020 to December 2023, we retrospectively analyzed CRKP-related pneumonia patients treated in two Chinese tertiary hospitals. Mortality was measured at 14 and 30 days as the primary outcome. Secondary outcomes included the 14-day microbiological cure rate and the 14-day clinical cure rate. Factors contributing to clinical failure were evaluated via both univariate analysis and multivariate logistic regression. To account for confounding factors, propensity score matching (PSM) was utilized. Among the 195 patients with CRKP infections, 103 (52.8 %) received CZA combination therapy, and 92 (47.2 %) patients received CZA monotherapy. The combination therapy group exhibited superior clinical and microbiological cure rates compared to the monotherapy group, with a 14-day clinical cure rate of 60.1 % vs. 45.7 % (P = 0.042) and a 14-day microbiological cure rate of 72.8 % vs. 58.6 % (P = 0.038), respectively. Combination therapy reduced mortality rates at 14 days (7.8 % vs. 17.4 %, P = 0.041), but not at 30 days (14.6 % vs. 25.0 %, P = 0.066). Even after using PSM, the group treated with the CZA combination continued to had a lower mortality rate at 14 days (5.9 % vs. 17.6 %, P = 0.039). The 14-day clinical cure rate for the combination therapy group was 63.2 %, and the 14-day microbial cure rate was 77.9 %. Both of these statistics were notably greater than those observed in the monotherapy group. Furthermore, the multivariate logistic regression model indicated a significant link between combination therapy and a decrease in clinical failure. Carbapenems were noted to be the most effective class of concomitant agents. Our findings indicate that patients with pneumonia due to CRKP benefit from combination treatment of CZA rather than monotherapy; administering carbapenem in combination with CZA in the early stages could provide considerable survival benefits.

Bacterial Infections in End-Stage Liver Disease: Implications for Liver Transplantation

Bacterial infections are a common complication in patients with decompensated liver cirrhosis. The complex landscape of cirrhosis, characterized by immune paralysis and an exhausted response to exogenous triggers, explains the higher prevalence of such infections, particularly in advanced disease stages. In clinical practice, the onset of a bacterial infection can lead to further deterioration of hepatic and extra-hepatic function, potentially resulting in acute decompensation or acute-on-chronic liver failure. This has significant clinical implications, particularly for patients awaiting a transplant. In this review, we will discuss the latest evidence on the diagnosis and therapy of bacterial infections in patients with decompensated cirrhosis. Additionally, we will analyze the impact of bacterial infections in the context of liver transplantation, discussing debated topics such as the timing of transplantation in patients with infections, potential implications for prioritization, effects on post-operative recovery, grafts, and patient survival.

Ceftazidime-avibactam induced renal disorders: past and present

With the increasing prevalence of multidrug-resistant Gram-negative bacterial pathogens worldwide, antimicrobial resistance has become a significant public health concern. Ceftazidime-avibactam (CAZ-AVI) exhibited excellent in vitro activity against many carbapenemase-producing pathogens, and was widely used for the treatment of various complicated infections. CAZ-AVI is well tolerated across all dosing regimens, and its associated acute kidney injury (AKI) in phase II/III clinical trials is rare. However, recent real-world studies have demonstrated that CAZ-AVI associated AKI was more frequent in real-world than in phase II and III clinical trials, particularly in patients receiving concomitant nephrotoxic agents, with critically ill patients being at a higher risk. Herein, we reviewed the safety data related to renal impairment of CAZ-AVI, and discussed its pharmacokinetic/pharmacodynamic targets and dosage adjustment in patients with impaired renal function. This review aimed to emphasize the importance for healthcare professionals to be aware of this adverse event of CAZ-AVI and provide practical insights into the dosage optimization in critically ill patients with renal dysfunction.

Antibiotic treatment in cirrhotic patients

In this editorial, we comment on the article by Liakina V: "Antibiotic resistance in patients with liver cirrhosis: Prevalence and current approach to tackle" (World J Clin Cases 2023, 11: 7530-7542). In this excellent review, Liakina presents current data on bacterial complications in patients with cirrhosis. Bacterial infections are the most common complication in patients with liver cirrhosis. We focus specifically on spontaneous bacterial peritonitis (SBP) which is the most representative infectious complication. Liakina V suggested starting empirically, in all patients with suspected SBP, third-generation cephalosporins when the number of polymorphonuclear leukocytes (PMNs) in ascites is greater than 250/mm3. This statement creates some doubts in our clinical practice so we discuss on the unsolved pitfalls of diagnosis and treatment that are often encountered in patients with ascitic fluid infections, especially on bacterascites that is defined as ascitic bacterial growth with PMNs below 250/mm3. The severity of liver disease and overall prognosis are highly comparable for patients with bacterascites and SBP in some recent well-conducted studies. Furthermore, we present a brief analysis of the prevalence of antibiotic-resistant isolates with an introduction of currently approved antibiotic drug options to treat ascitic fluid infections avoiding antibiotic resistance. In light of the most recent epidemiological data, third-generation cephalosporins should not be considered as an empirical antibiotic treatment of choice for ascitic fluid infections.