Outcomes of treating AmpC-producing Enterobacterales bacteraemia with carbapenems vs. non-carbapenems

Early Treatment Outcomes for Bloodstream Infections Caused by Potential AmpC Beta-Lactamase-Producing Enterobacterales with Focus on Piperacillin/Tazobactam: A Retrospective Cohort Study

“…In accordance with the findings of a recent retrospective cohort study including 241 patients with SPICE-BSI that was conducted at two university teaching hospitals in Singapore [16], Enterobacter spp. (52.5%) were the most common SPICE organisms isolated from our patients' BCs, and carbapenems (28%) and piperacillin/tazobactam (27%) were the most common active empiric antibiotics used.…”

“…In contrast, pneumonia (27.8%) was the most common source of bacteremia in the present study (23.5% in the empiric piperacillin/tazobactam group and 35.4% in the empiric carbapenem group), and patients in the empiric piperacillin/tazobactam group had the lowest rate of urinary tract infection (8.6%). Contrary, in the Singapore study by Tan et al, urinary tract infection and vascular catheters were the most common sources of bacteremia [16]. Recent studies comparing carbapenem and non-carbapenem therapy regimens for SPICE-BSI have mentioned adequate source control as a prerequisite for successful therapy with piperacillin/tazobactam [11,13].…”

“…In the present study, the piperacillin/tazobactam and meropenem group had similar rates of early source control. However, it has previously been theorized that the focus of infection cannot be detected properly in a relevant number of cases [16]. In fact, patients in the piperacillin/tazobactam group had a high rate of unknown focus, occurring in 24.7% of patients.…”

“…Although carbapenems are the gold standard for treatment of severe infections, alternative carbapenem-sparing treatment options are needed [10][11][12]14] to prevent increases in carbapenem resistance [15]. Whereas most previous studies have assessed treatment outcomes by comparing 30-day mortality rates among different treatment regimens [10,11,16,17], this study focused on early treatment response on day 3 as the primary outcome. The main findings of our study were that early treatment response was significantly lower in the piperacillin/tazobactam group than in the carbapenem group (p = 0.006) despite similar disease severities (median SOFA score: 3.0 versus 4.5, p > 0.2) and that empiric piperacillin/tazobactam use (AOR 0.25, p < 0.001), baseline SOFA score (AOR 0.83, p < 0.001) and liver comorbidity (AOR 0.32, p = 0.018) were independently associated with early treatment failure.…”

An Evidence-Based Multidisciplinary Approach Focused at Creating Algorithms for Targeted Therapy of BSIs, cUTIs, and cIAIs Caused by Enterobacterales in Critically Ill Adult Patients

“…No significant difference in mortality rate was found for both empiric (OR 0.60; CI 0.17–2.20) or definitive therapy (OR 0.61; CI 0.27–1.38). Tamma et al, 2013 61 Prospective propensity score matched cohort 78 (46 CEF vs 32 MER) Cefepime (1–2 g q8h) vs Meropenem (1–2 g q8h) Dose adjustment for renal impairment 40 HAP 38 BSI 38 cIAI 51 E. cloacae 31 E. aerogenes 13 S. marcescens 1 C. freundii ICU admission 42.7% vs 62.5% Mechanical ventilation 29.2% vs 37.5% Septic shock 22.9% vs 34.4% Immunocompromised 29.2% vs 50% No difference in 30-day mortality rate (OR 0.63 95% CI 0.23–2.11) No difference in hospital length of stay (OR 0.96 95% CI 0.79–1.26) Relapse 25% Resistance 1.6% (in cefepime group) Cefepime may be a reasonable option for the treatment of invasive infections due to AmpC β- lactamase–producing organisms Tan et al, 2020 64 Retrospective cohort study 241 of which 189 with definitive therapy with CEF (N=57) or carbapenems (N=132) CEF (N=57) vs IMI (N=16) or MER (N=55) or ERT (N=61) 55 cUTI 53 CR-BSI 46 cIAI 30 Pneumonia 13 SSTI 44 others All BSI 140 Enterobacter spp 54 Serratia spp 40 M. morganii 5 C. freundii 2 Providencia spp ICU admission 21.6% 30-day mortality rate: 5.3% CEF vs 18.9% carbapenems (p=0.02) At multivariate analysis carbapenems not associated with significant higher mortality compared to CEF (OR 2.25; CI 0.86–5.91) NA Empirical PIP/TZB and definitive CEF were not associated with 30-day mortality compared to carbapenems Cheng et al, 2017 66 Retrospective matched case-control 165 (88 PIP/TZB vs 77 CEF or MER) PIP-TZB vs CEF or MER 33 cIAI 31 cUTI 28 HAP/VAP 22 CR-BSI ...…”