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Frescas BE, McCoy CM, Kirby J, Bowden R, Mercuro NJ. Outcomes associated with empiric cefepime for bloodstream infections caused by ceftriaxone-resistant, cefepime-susceptible Escherichia coli and Klebsiella pneumoniae. Int J Antimicrob Agents 2023; 61:106762. [PMID: 36804369 DOI: 10.1016/j.ijantimicag.2023.106762] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Cefepime is a first-line agent for empiric sepsis therapy; however, cefepime use may be associated with increased mortality for extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) in an MIC-dependent manner. This study aimed to compare the efficacy of empiric cefepime versus meropenem for bloodstream infections (BSI) caused by ceftriaxone-resistant Escherichia coli and Klebsiella pneumoniae with cefepime MICs ≤ 2 mg/L. METHODS This single-center retrospective cohort study included patients admitted from October 2010 to August 2020 who received cefepime or meropenem empirically for sepsis with a blood culture growing ceftriaxone-resistant Escherichia coli or Klebsiella pneumoniae. The primary outcome was 30-day mortality; secondary endpoints included 14-day mortality, recurrent BSI, readmission and recurrent infection within 90 days, time to clinical resolution of infection, time to clinical stability, and clinical stability at 48 hours. RESULTS Fifty-four patients met inclusion criteria: 36 received meropenem and 18 received cefepime. The median (IQR) treatment durations of cefepime and meropenem were 3 (2-6) days and 7 (5-10) days, respectively. Thirty-day and 14-day mortality were similar between cefepime and meropenem (11.1% vs. 2.8%; P = 0.255 and 5.6% vs. 2.8%; P = 1.00, respectively). Cefepime was associated with longer time to clinical stability compared with meropenem (median 38.48 hours vs. 21.26; P = 0.016). CONCLUSION Mortality was similar between groups, although most patients who received cefepime empirically were ultimately transitioned to a carbapenem to complete the full treatment course. Empiric cefepime was associated with a delay in achieving clinical stability when compared with meropenem to treat BSI caused by ceftriaxone-resistant Enterobacterales, even when cefepime-susceptible.
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Affiliation(s)
- Brian E Frescas
- Department of Pharmacy, Christus Spohn Health System, Corpus Christi, TX, USA.
| | - Christopher M McCoy
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - James Kirby
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert Bowden
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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2
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Mills JP, Marchaim D. Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update. Infect Dis Clin North Am 2021; 35:969-994. [PMID: 34752228 DOI: 10.1016/j.idc.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, University of Michigan Medical School, F4177 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5226, USA.
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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3
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Adler A, Katz DE, Marchaim D. The Continuing Plague of Extended-Spectrum β-Lactamase Producing Enterbacterales Infections: An Update. Infect Dis Clin North Am 2020; 34:677-708. [PMID: 33011052 DOI: 10.1016/j.idc.2020.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, that is, the most common human pathogens outside of the hospital setting. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This poses an enormous burden and threat to public health. This article aims to narrate the evolving epidemiology of ESBL infections and highlights current challenges in terms of management and prevention of these common infections.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 6423906 Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David E Katz
- Division of Internal Medicine, Shaare Zedek Medical Center, 12 Shmuel Bait Street, Jerusalem 9103102, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.
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4
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Pogue JM, Heil EL. Laces out Dan! The role of tazobactam based combinations for invasive ESBL infections in a post-MERINO world. Expert Opin Pharmacother 2019; 20:2053-2057. [PMID: 31496320 DOI: 10.1080/14656566.2019.1663827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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5
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Najmi A, Karimi F, Kunhikatta V, Varma M, Nair S. Resistance Trend, Antibiotic Utilization and Mortality in Patients with E. coli Bacteraemia. Open Access Maced J Med Sci 2019; 7:1119-1123. [PMID: 31049092 PMCID: PMC6490482 DOI: 10.3889/oamjms.2019.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: Incidence of bacteraemia and driving concerns about antibiotic resistance is increasing globally. Risk factors for developing antimicrobial resistance are antibiotic overuse, incorrect dosing and extended duration of administration. AIM: This study was conducted to examine the prescription and susceptibility pattern of antibiotics in bacteraemia patients with ESBL producing and Non-ESBL-producing E. coli and their correlation with mortality. METHODS: Data were collected from medical records of the patients aged 18 years and above, diagnosed with E. coli bacteremia from January 2013 through July 2017. Institutional ethics committee approval was obtained before the study (IEC 483/2017). Cumulative sensitivity/resistance pattern of isolated microorganisms and DDD/100 bed days of prescribed antibiotics were obtained. RESULTS: 182 cases of E. coli bacteraemia were reviewed. 59.9% (n = 109) were male with an age range of 20-90 years. The mortality rate was 24.9% (n = 44). 55.5% (n = 101) of the isolated organisms were ESBL-producing. A high percentage of resistance to cephalosporins and fluoroquinolones were observed among the patients, and most of the identified isolates were sensitive to the aminoglycosides, carbapenems and β-lactam and β-lactamase inhibitor combinations (BLBLIs). CONCLUSIONS: Frequent utilisation of the high-end antibiotics and increase in microorganism’s resistance to different antibiotics can lead to a worrisome level. Local antibiotic resistance data and consumption policy are essential to prevent and slow down this process. We observed a descending resistance trend for amoxicillin-clavulanic acid combination in our setting to both the ESBL producing and non-producing.
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Affiliation(s)
- Amirreza Najmi
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Fateme Karimi
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vijayanarayan Kunhikatta
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Muralidhar Varma
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sreedharan Nair
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
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6
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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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7
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Adler A, Katz DE, Marchaim D. The Continuing Plague of Extended-spectrum β-lactamase-producing Enterobacteriaceae Infections. Infect Dis Clin North Am 2017; 30:347-375. [PMID: 27208763 DOI: 10.1016/j.idc.2016.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, which is the most common human pathogens outside of the hospital settings. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This development poses an enormous burden and threat to public health. This paper aims to narrate the evolving epidemiology of ESBL infections, and highlight current challenges in terms of management and prevention of these common infections.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David E Katz
- Department of Internal Medicine D, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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8
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Chang YT, Coombs G, Ling T, Balaji V, Rodrigues C, Mikamo H, Kim MJ, Rajasekaram DG, Mendoza M, Tan TY, Kiratisin P, Ni Y, Barry W, Xu Y, Chen YH, Hsueh PR. Epidemiology and trends in the antibiotic susceptibilities of Gram-negative bacilli isolated from patients with intra-abdominal infections in the Asia-Pacific region, 2010-2013. Int J Antimicrob Agents 2017; 49:734-739. [PMID: 28435019 DOI: 10.1016/j.ijantimicag.2017.01.030] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/25/2017] [Accepted: 01/28/2017] [Indexed: 10/19/2022]
Abstract
This study was conducted to investigate the epidemiology and antimicrobial susceptibility patterns of Gram-negative bacilli (GNB) isolated from intra-abdominal infections (IAIs) in the Asia-Pacific region (APR) from 2010-2013. A total of 17 350 isolates were collected from 54 centres in 13 countries in the APR. The three most commonly isolated GNB were Escherichia coli (46.1%), Klebsiella pneumoniae (19.3%) and Pseudomonas aeruginosa (9.8%). Overall, the rates of extended-spectrum β-lactamase (ESBL)-producing E. coli and K. pneumoniae were 38.2% and 24.3%, respectively, and they were highest in China (66.6% and 38.7%, respectively), Thailand (49.8% and 36.5%, respectively) and Vietnam (47.9% and 30.4%, respectively). During 2010-2013, the rates of ESBL-producing E. coli and K. pneumoniae isolates causing community-associated (CA) IAIs (collected <48 h after admission) were 26.0% and 13.5%, respectively, and those causing hospital-associated (HA) IAIs were 48.0% and 30.6%, respectively. Amikacin, ertapenem and imipenem were the most effective agents against ESBL-producing isolates. Piperacillin/tazobactam displayed good in vitro activity (91.4%) against CA ESBL-producing E. coli. For other commonly isolated Enterobacteriaceae, fluoroquinolones, cefepime and carbapenems exhibited better in vitro activities than third-generation cephalosporins. Amikacin possessed high in vitro activity against all GNB isolates (>80%) causing IAIs, except for Acinetobacter calcoaceticus-baumannii (ACB) complex (30.9% for HA-IAI isolates). All of the antimicrobial agents tested exhibited <45% in vitro activity against ACB complex. Antimicrobial resistance is a persistent threat in the APR and continuous monitoring of evolutionary trends in the susceptibility patterns of GNB causing IAIs in this region is mandatory.
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Affiliation(s)
- Ya-Ting Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, Graduate Institute of Medicine, Sepsis Research Center, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Thomas Ling
- Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China
| | - V Balaji
- Christian Medical College, Vellore, India
| | - Camilla Rodrigues
- P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | | | - Min-Ja Kim
- Korea University Anam Hospital, Seoul, South Korea
| | | | | | | | | | | | | | - Yingchun Xu
- Peking Union Medical College Hospital, Beijing, China
| | - Yen-Hsu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; School of Medicine, Graduate Institute of Medicine, Sepsis Research Center, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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9
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Adler A, Friedman ND, Marchaim D. Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications. Infect Dis Clin North Am 2016; 30:967-997. [PMID: 27660090 DOI: 10.1016/j.idc.2016.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Dror Marchaim
- Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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10
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Wang R, Cosgrove SE, Tschudin-Sutter S, Han JH, Turnbull AE, Hsu AJ, Avdic E, Carroll KC, Tamma PD. Cefepime Therapy for Cefepime-Susceptible Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae Bacteremia. Open Forum Infect Dis 2016; 3:ofw132. [PMID: 27419191 PMCID: PMC4942761 DOI: 10.1093/ofid/ofw132] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 05/16/2016] [Indexed: 11/27/2022] Open
Abstract
The role of cefepime for extended-spectrum β-lactamase (ESBL) bacteremia is unclear if susceptible in vitro. In a propensity score-matched study of patients with ESBL bacteremia, risk of death was 2.87 times higher for patients receiving cefepime compared with carbapenems (95% confidence interval [CI], .88–9.41). We compared 14-day mortality of patients with ESBL bacteremia receiving empiric cefepime versus empiric carbapenem therapy in a propensity score-matched cohort. There was a trend towards increased mortality in the cefepime group (hazard ratio, 2.87; 95% CI, .88–9.41), which enhances the existing literature suggesting that cefepime may be suboptimal for invasive ESBL infections.
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Affiliation(s)
- Ruibin Wang
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jennifer H Han
- Divisions of Infectious Diseases and Epidemiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Alice J Hsu
- Department of Pharmacy, The Johns Hopkins Hospital
| | - Edina Avdic
- Department of Pharmacy, The Johns Hopkins Hospital
| | - Karen C Carroll
- Division of Medical Microbiology, The Johns Hopkins University School of Medicine
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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Impact of CLSI Breakpoint Changes on Microbiology Laboratories and Antimicrobial Stewardship Programs. J Clin Microbiol 2016; 54:840-4. [PMID: 26791363 DOI: 10.1128/jcm.02424-15] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In 2010, the Clinical and Laboratory Standards Institute (CLSI) lowered the MIC breakpoints for many beta-lactam antibiotics to enhance detection of known resistance amongEnterobacteriaceae The decision to implement these new breakpoints, including the changes announced in both 2010 and 2014, can have a significant impact on both microbiology laboratories and antimicrobial stewardship programs. In this commentary, we discuss the changes and how implementation of these updated CLSI breakpoints requires partnership between antimicrobial stewardship programs and the microbiology laboratory, including data on the impact that the changes had on antibiotic usage at our own institution.
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12
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Carbapenems Versus Piperacillin-Tazobactam for Bloodstream Infections of Nonurinary Source Caused by Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae. Infect Control Hosp Epidemiol 2015; 36:981-5. [PMID: 25990361 DOI: 10.1017/ice.2015.101] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A recent, frequently quoted study has suggested that for bloodstream infections (BSIs) due to extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL) Escherichia coli, treatment with β-lactam/β-lactamase inhibitors (BLBLIs) might be equivalent to treatment with carbapenems. However, the majority of BSIs originate from the urinary tract. A multicenter, multinational efficacy analysis was conducted from 2010 to 2012 to compare outcomes of patients with non-urinary ESBL BSIs who received a carbapenem (69 patients) vs those treated with piperacillin-tazobactam (10 patients). In multivariate analysis, therapy with piperacillin-tazobactam was associated with increased 90-day mortality (adjusted odds ratio, 7.9, P=.03). For ESBL BSIs of a non-urinary origin, carbapenems should be considered a superior treatment to BLBLIs.
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13
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Tal Jasper R, Coyle JR, Katz DE, Marchaim D. The complex epidemiology of extended-spectrum β-lactamase-producing Enterobacteriaceae. Future Microbiol 2015; 10:819-39. [DOI: 10.2217/fmb.15.16] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
ABSTRACT Antimicrobial resistance is a growing worldwide iatrogenic complication of modern medical care. Extended-spectrum β-lactamases have emerged as one of the most successful resistance mechanisms, limiting our therapeutic options to treat various human infections. The dissemination of these enzymes to the community probably signifies an irreversible step. This paper will review the evolution of human infections associated with extended-spectrum β-lactamase-producing organisms in the past 20 years, and will present and discuss the current challenges, controversies, debates and knowledge gaps in this research field.
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Affiliation(s)
- Ruthy Tal Jasper
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Joseph R Coyle
- Division of Communicable Diseases, Bureau of Disease Control, Prevention & Epidemiology, Michigan Department of Community Health, 201 Townsend St, Lansing, MI, USA, 48909
| | - David E Katz
- Department of Internal Medicine D, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel
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14
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Tamma PD, Han JH, Rock C, Harris AD, Lautenbach E, Hsu AJ, Avdic E, Cosgrove SE. Carbapenem therapy is associated with improved survival compared with piperacillin-tazobactam for patients with extended-spectrum β-lactamase bacteremia. Clin Infect Dis 2015; 60:1319-25. [PMID: 25586681 DOI: 10.1093/cid/civ003] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 10/13/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The effectiveness of piperacillin-tazobactam (PTZ) for the treatment of extended-spectrum β-lactamase (ESBL) bacteremia is controversial. We compared 14-day mortality of PTZ vs carbapenems as empiric therapy in a cohort of patients with ESBL bacteremia who all received definitive therapy with a carbapenem. METHODS Patients hospitalized between January 2007 and April 2014 with monomicrobial ESBL bacteremia were included. A decrease of >3 doubling dilutions in the minimum inhibitory concentration for third-generation cephalosporins tested in combination with 4 µg/mL of clavulanic acid was used to confirm ESBL status. The primary exposure was empiric therapy, defined as antibiotic therapy administered to a patient before ESBL status was known. Patients were excluded if they did not receive a carbapenem after ESBL production was identified. The primary outcome was time to death from the first day of bacteremia. Propensity scores using inverse probability of exposure weighting (IPW) were used to estimate the probability that a patient would receive PTZ vs carbapenems empirically. We calculated overall hazard ratios for mortality censored at 14 days using Cox proportional hazards models on an IPW-adjusted cohort. RESULTS A total of 331 unique patients with ESBL bacteremia were identified. One hundred three (48%) patients received PTZ empirically and 110 (52%) received carbapenems empirically. The adjusted risk of death was 1.92 times higher for patients receiving empiric PTZ compared with empiric carbapenem therapy (95% confidence interval, 1.07-3.45). CONCLUSIONS PTZ appears inferior to carbapenems for the treatment of ESBL bacteremia. For patients at high risk of invasive ESBL infections, early carbapenem therapy should be considered. Our findings should not be extended to β-lactam/β-lactamase inhibitor combinations in development, as limited clinical data are available for these agents.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer H Han
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia
| | - Clare Rock
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Ebbing Lautenbach
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia
| | - Alice J Hsu
- Department of Pharmacy, Johns Hopkins Hospital
| | - Edina Avdic
- Department of Pharmacy, Johns Hopkins Hospital
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Curello J, MacDougall C. Beyond Susceptible and Resistant, Part II: Treatment of Infections Due to Gram-Negative Organisms Producing Extended-Spectrum β-Lactamases. J Pediatr Pharmacol Ther 2014; 19:156-64. [PMID: 25309145 DOI: 10.5863/1551-6776-19.3.156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The production of β-lactamase is the most common mechanism of resistance to β-lactam antibiotics among gram-negative bacteria. Extended-spectrum β-lactamases (ESBLs) are capable of hydrolyzing most penicillins, extended-spectrum cephalosporins, and aztreonam, but their activity is suppressed in the presence of a β-lactamase inhibitor. Serious infections with ESBL-producing isolates are associated with high rates of mortality, making early detection and adequate medical management essential to ensure optimal patient outcomes. Much controversy has centered on the recommendations for testing and reporting of antibiotic susceptibility of potential ESBL-producing organisms. The latest version of the Clinical Laboratory Standards Institute (CLSI) susceptibility reporting guidelines, published in 2010, no longer advocates for phenotypic testing of ESBL-producing isolates. From newer studies demonstrating a correlation between organism minimum inhibitory concentration (MIC) and clinical outcome, along with pharmacokinetic/pharmacodynamic (PK/PD) modeling demonstrating the importance of the MIC to achieving therapeutic targets, the CLSI has assigned lower susceptibility breakpoints for aztreonam and most cephalosporins. The new guidelines recommend using the lower MIC breakpoints to direct antibiotic selection. This article reviews the microbiology and epidemiology of ESBLs, the recent change in CLSI susceptibility reporting guidelines for ESBLs, and the clinical and PK/PD data supporting the relationship between in vitro susceptibility and clinical outcome. Finally, considerations for antimicrobial selection when treating patients with infections caused by ESBL-producing organisms from various sources are discussed.
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Affiliation(s)
- Jennifer Curello
- Department of Pharmaceutical Services, University of California Los Angeles Medical Center, Los Angeles, California
| | - Conan MacDougall
- Department of Clinical Pharmacy, University of California, San Francisco School of Pharmacy, San Francisco, California
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Stokkou S, Tammer I, Zibolka S, Grabau C, Geginat G. Impact of minimal inhibitory concentration breakpoints on local cumulative bacterial susceptibility data and antibiotic consumption. BMC Res Notes 2014; 7:603. [PMID: 25185565 PMCID: PMC4161835 DOI: 10.1186/1756-0500-7-603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/28/2014] [Indexed: 11/17/2022] Open
Abstract
Background The phenotypic antimicrobial susceptibility testing (AST) of bacteria depends on minimal inhibitory concentration breakpoints issued by national and international breakpoint committees. The current study was performed in order to test the influence of different AST standards on local cumulative AST data and on antibiotic consumption. Methods Automated AST was performed with clinical isolates of Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, and E. faecium. From each species 100 prospectively collected non-duplicate clinical isolates were tested and MIC data were interpreted according to the interpretation standards issued by DIN and EUCAST, respectively. In addition cumulative AST data from clinical isolates and antibiotic consumption were monitored before and after implementation of new EUCAST MIC breakpoints. Results The susceptibility rate of P. aeruginosa against piperacillin and gentamicin, and of C. freundii against piperacillin/tazobactam increased significantly, whereas the susceptibility rates of E. cloacae, S. marcescens, and M. morganii against ciprofloxacin decreased significantly after switching from DIN to EUCAST MIC breakpoints. These changes in the cumulative antibiotic resistance pattern were reflected by enhanced consumption of piperacillin/tazobactam after implementation of EUCAST MIC breakpoints. Conclusions These data show that changes of AST breakpoints have a significant influence on local cumulative AST data and on antibiotic consumption.
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Affiliation(s)
| | | | | | | | - Gernot Geginat
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Universitätsklinikum Magdeburg, Leipziger Str, 44, 39120 Magdeburg, Germany.
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Determining the optimal ceftriaxone MIC for triggering extended-spectrum β-lactamase confirmatory testing. J Clin Microbiol 2014; 52:2228-30. [PMID: 24740077 DOI: 10.1128/jcm.00716-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As routine testing of clinical isolates for extended-spectrum β-lactamase (ESBL) production (screen plus phenotypic confirmatory testing) is no longer required by the Clinical and Laboratory Standards Institute (CLSI), a number of clinical microbiology laboratories use ceftriaxone MICs as a proxy means of identifying bacteria as potential ESBL producers. Data from 1,386 clinical isolates suggest that a ceftriaxone MIC cutoff of 8 μg/ml is an excellent predictor of ESBL production, with a positive predictive value and negative predictive value approaching 100% and 99.5%, respectively.
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18
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Hsu AJ, Tamma PD. Treatment of multidrug-resistant Gram-negative infections in children. Clin Infect Dis 2014; 58:1439-48. [PMID: 24501388 DOI: 10.1093/cid/ciu069] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Antibiotic resistance in conjunction with the erosion of the drug development pipeline may lead us into a bleak future, a "post-antibiotic era." Because of a shortage of studies addressing treatment options for multidrug-resistant Gram-negative (MDRGN) infections in children, data must be extrapolated from the adult literature. However, even adult studies are limited by significant methodological flaws. We are in urgent need of pediatric specific pharmacokinetic/pharmacodynamic data for agents with activity against MDRGN infections as well as improved clinical outcomes studies. For the time being, we must rely on in vitro studies, observational data, and clinical experience to guide our therapeutic decisions. In this review, we discuss treatment considerations for infections caused by extended-spectrum β-lactamase-producing organisms, AmpC β-lactamase-producing organisms, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii in the pediatric population.
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Affiliation(s)
- Alice J Hsu
- Department of Pharmacy, Division of Pediatric Pharmacy, The Johns Hopkins Hospital
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Alexander EL, Satlin MJ, Gamaletsou MN, Sipsas NV, Walsh TJ. Worldwide challenges of multidrug-resistant bacteria in patients with hematologic malignancies. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The emergence of infections due to multidrug-resistant (MDR) bacteria poses a major public health threat to all patients, but patients with hematologic malignancies are especially at risk. A common thread across all classes of bacteria is that increased reliance on and usage of broad-spectrum antibacterial agents, combined with the intrinsic ability of bacteria to develop and transmit resistance-conferring mutations, has led to the widespread dissemination of MDR organisms. In this article, we summarize the most worrisome MDR bacteria, assess their clinical impact on patients with hematologic malignancies and outline measures that are required to mitigate this impact.
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Affiliation(s)
| | - Michael J Satlin
- Division of Infectious Diseases, Weill Cornell Medical Center, New York, NY, USA
- Transplantation–Oncology Infectious Diseases Program, Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Maria N Gamaletsou
- University of Athens School of Medicine & Laikon Hospital, Athens, Greece
| | - Nikolaos V Sipsas
- University of Athens School of Medicine & Laikon Hospital, Athens, Greece
| | - Thomas J Walsh
- Department of Pediatrics, Weill Cornell Medical Center, New York, NY, USA
- Department of Microbiology & Immunology, Weill Cornell Medical Center, New York, NY, USA
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Outcomes of children with enterobacteriaceae bacteremia with reduced susceptibility to ceftriaxone: do the revised breakpoints translate to improved patient outcomes? Pediatr Infect Dis J 2013; 32:965-9. [PMID: 23470679 DOI: 10.1097/inf.0b013e31829043b3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND In 2010, the Clinical and Laboratory Standards Institute (CLSI) revised and lowered the ceftriaxone minimum inhibitory concentration breakpoints for Enterobacteriaceae and removed the requisite extended spectrum β-lactamase phenotypic testing for organisms with elevated minimum inhibitory concentrations. The impact that these recommendations have on clinical outcomes of children have not been previously evaluated. METHODS We conducted a retrospective study to compare clinical outcomes between children treated with ceftriaxone and those treated with broader spectrum β-lactams for Enterobacteriaceae bacteremia with reduced susceptibility (minimum inhibitory concentrations 4-8 µg/mL) to ceftriaxone according to the new CLSI interpretive criteria. Mortality and microbiological relapse were evaluated using a multivariable logistic regression model. RESULTS There were a total of 783 unique children with Enterobacteriaceae bacteremia during the study period. Using the CLSI breakpoints before 2010, 76 children would have had clinical isolates resistant to ceftriaxone. With the revised breakpoints, 229 Enterobacteriaceae isolates would no longer be susceptible to ceftriaxone (>300% increase). Of the 136 children who met eligibility criteria, 63 children received ceftriaxone and 73 children received broader spectrum β-lactams. There was no difference in 30-day mortality (odds ratio 0.81, 95% confidence interval: 0.31-2.59) or microbiological relapse (odds ratio 0.97, 95% confidence interval: 0.36-2.66) between the groups. CONCLUSIONS Our findings do not support the proposed clinical benefit of more conservative CLSI breakpoints. The revised breakpoints promote increased broad-spectrum β-lactam use. The need for lowered ceftriaxone breakpoints against Enterobacteriaceae in children needs to be reevaluated in larger prospective studies.
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Tamma PD, Powers JH. Do patient data really support the clinical and laboratory standards institute recommendation for lowering third-generation cephalosporin interpretive breakpoints? Clin Infect Dis 2013; 57:624-5. [PMID: 23658433 DOI: 10.1093/cid/cit308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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