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Stewart AG, Paterson DL, Young B, Lye DC, Davis JS, Schneider K, Yilmaz M, Dinleyici R, Runnegar N, Henderson A, Archuleta S, Kalimuddin S, Forde BM, Chatfield MD, Bauer MJ, Lipman J, Harris-Brown T, Harris PNA. Meropenem Versus Piperacillin-Tazobactam for Definitive Treatment of Bloodstream Infections Caused by AmpC β-Lactamase-Producing Enterobacter spp, Citrobacter freundii, Morganella morganii, Providencia spp, or Serratia marcescens: A Pilot Multicenter Randomized Controlled Trial (MERINO-2). Open Forum Infect Dis 2021; 8:ofab387. [PMID: 34395716 PMCID: PMC8361238 DOI: 10.1093/ofid/ofab387] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background Carbapenems are recommended treatment for serious infections caused by AmpC-producing gram-negative bacteria but can select for carbapenem resistance. Piperacillin-tazobactam may be a suitable alternative. Methods We enrolled adult patients with bloodstream infection due to chromosomal AmpC producers in a multicenter randomized controlled trial. Patients were assigned 1:1 to receive piperacillin-tazobactam 4.5 g every 6 hours or meropenem 1 g every 8 hours. The primary efficacy outcome was a composite of death, clinical failure, microbiological failure, and microbiological relapse at 30 days. Results Seventy-two patients underwent randomization and were included in the primary analysis population. Eleven of 38 patients (29%) randomized to piperacillin-tazobactam met the primary outcome compared with 7 of 34 patients (21%) in the meropenem group (risk difference, 8% [95% confidence interval {CI}, –12% to 28%]). Effects were consistent in an analysis of the per-protocol population. Within the subcomponents of the primary outcome, 5 of 38 (13%) experienced microbiological failure in the piperacillin-tazobactam group compared to 0 of 34 patients (0%) in the meropenem group (risk difference, 13% [95% CI, 2% to 24%]). In contrast, 0% vs 9% of microbiological relapses were seen in the piperacillin-tazobactam and meropenem arms, respectively. Susceptibility to piperacillin-tazobactam and meropenem using broth microdilution was found in 96.5% and 100% of isolates, respectively. The most common AmpC β-lactamase genes identified were blaCMY-2, blaDHA-17, blaCMH-3, and blaACT-17. No ESBL, OXA, or other carbapenemase genes were identified. Conclusions Among patients with bloodstream infection due to AmpC producers, piperacillin-tazobactam may lead to more microbiological failures, although fewer microbiological relapses were seen. Clinical Trials Registration NCT02437045.
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Affiliation(s)
- Adam G Stewart
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - David L Paterson
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Barnaby Young
- National Centre for Infectious Disease, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - David C Lye
- National Centre for Infectious Disease, Singapore.,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joshua S Davis
- Infectious Disease Department, John Hunter Hospital, Newcastle, Australia.,Menzies School of Health Research, Darwin, Australia
| | - Kellie Schneider
- Infectious Disease Department, John Hunter Hospital, Newcastle, Australia
| | - Mesut Yilmaz
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Istanbul Medipol, Turkey
| | - Rumeysa Dinleyici
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Istanbul Medipol, Turkey
| | - Naomi Runnegar
- Infection Management Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrew Henderson
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Infection Management Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Sophia Archuleta
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore.,Program in Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore
| | - Brian M Forde
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia.,Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
| | - Mark D Chatfield
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Michelle J Bauer
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Jeffrey Lipman
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Scientific Consultant, Nimes University Hospital, University of Montpellier, Nimes, France
| | | | - Patrick N A Harris
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
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