Bloodstream infections due to extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae: risk factors for mortality and treatment outcome, with special emphasis on antimicrobial therapy.

Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
Antimicrobial Agents and Chemotherapy (Impact Factor: 4.45). 12/2004; 48(12):4574-81. DOI: 10.1128/AAC.48.12.4574-4581.2004
Source: PubMed

ABSTRACT This study was conducted to evaluate risk factors for mortality and treatment outcome of bloodstream infections due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EK). ESBL production in stored K. pneumoniae and E. coli blood isolates from Jan 1998 to Dec 2002 was phenotypically determined according to NCCLS guidelines and/or the double-disk synergy test. A total of 133 patients with ESBL-EK bacteremia, including 66 patients with ESBL-producing K. pneumoniae and 67 with ESBL-producing E. coli, were enrolled. The overall 30-day mortality rate was 25.6% (34 of 133). Independent risk factors for mortality were severe sepsis, peritonitis, neutropenia, increasing Acute Physiology and Chronic Health Evaluation II score, and administration of broad-spectrum cephalosporin as definitive antimicrobial therapy (P < 0.05 for each of these risk factors). In 117 of the 133 patients, excluding 16 patients who died within 3 days after blood culture sample acquisition, the 30-day mortality rates according to definitive antibiotics were as follows: carbapenem, 12.9% (8 of 62); ciprofloxacin, 10.3% (3 of 29); and others, such as cephalosporin or an aminoglycoside, 26.9% (7 of 26). When patients who received appropriate definitive antibiotics, such as carbapenem or ciprofloxacin, were evaluated, mortality in patients receiving inappropriate empirical antimicrobial therapy was found not to be significantly higher than mortality in those receiving appropriate empirical antimicrobial therapy (18.9 versus 15.5%; P = 0.666). Carbapenem and ciprofloxacin were the most effective antibiotics in antimicrobial therapy for ESBL-EK bacteremia. A delay in appropriate definitive antimicrobial therapy was not associated with higher mortality if antimicrobial therapy was adjusted appropriately according to the susceptibility results. Our data suggest that more prudent use of carbapenem as empirical antibiotic may be reasonable.

Download full-text


Available from: Sung-Han Kim, Jun 26, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To study the comparative mortality associated with carbapenems and alternative antibiotics for the treatment of patients with extended-spectrum -lactamase (ESBL)-positive Enterobacteriaceae bacteraemia. We searched systematically PubMed and Scopus databases for studies providing data for mortality among patients treated with carbapenems, -lactam/-lactamase inhibitor combinations (BL/BLIs) or non-BL/BLIs (mainly cephalosporins and fluoroquinolones), preferably as monotherapy. Studies focusing on patients of all ages with community- and healthcare-associated bacteraemia were eligible. Data were pooled using the technique of meta-analysis. Twenty-one articles, studying 1584 patients, were included. Escherichia coli and Klebsiella pneumoniae were the most commonly studied bacteria. Delay in appropriate treatment up to 6 days was reported. Carbapenems were used mainly as definitive therapy. Carbapenems were associated with lower mortality than non- BL/BLIs for definitive [risk ratio (RR) 0.65, 95 CI 0.470.91] and empirical (RR 0.50, 95 CI 0.330.77) treatment. No statistically significant differences in mortality were found between carbapenems and BL/BLIs administered as definitive (RR 0.52, 95 0.231.13) or empirical (RR 0.91, 95 CI 0.661.25) treatment. BL/BLIs were not associated with lower mortality than non-BL/BLIs administered either definitively (RR 1.59, 95 0.833.06) or empirically (RR 0.82, 95 0.481.41). Data regarding subgroups according to the setting, comorbidity and bacterial species could not be extracted. Based on data from non-randomized studies, carbapenems may be considered the treatment of choice for empirical treatment of patients with ESBL-producing Enterobacteriaceae bacteraemia. The role of BL/BLIs should be further evaluated for definitive treatment. Further research should focus on faster identification of ESBL-positive pathogens and potential differences in the treatment of each bacterial species.
    Journal of Antimicrobial Chemotherapy 08/2012; 67(12). DOI:10.1093/jac/dks301 · 5.44 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A case-control study was performed with the objective of analysing risk factors and clinical features of infections caused by plasmid-mediated AmpC beta-lactamase (plasmid AmpC)-producing Enterobacteriaceae. All patients infected with plasmid AmpC-producing Enterobacteriaceae in two tertiary care hospitals from December 2006 to August 2007 were included. Plasmid AmpC enzymes were characterised by isoelectric focusing, enzyme inhibition assay and enzyme-specific polymerase chain reaction. A total of 30 patients (20 with Klebsiella pneumoniae and 10 with Escherichia coli) were recruited prospectively. CMY-2 and DHA-1 were the most common plasmid AmpC in E. coli and K. pneumoniae, respectively. An independent risk factor for infection with plasmid AmpC-producing Enterobacteriaceae was the use of an oxyimino-cephalosporin within 1 month of plasmid AmpC infection [adjusted odds ratio (aOR), 10.8, 95% confidence interval (CI), 1.6-75.4; P=0.016], with the use of a urinary catheter showing borderline significance (aOR, 6, 95% CI 0.93-38.4; P=0.06). An independent risk factor for treatment failure at 72 h was infection due to plasmid AmpC-producing Enterobacteriaceae (aOR, 9.78, 95% CI 1.34-71.17; P=0.02). These results suggest that infections caused by plasmid AmpC-producing isolates significantly increase treatment failure at 72 h and that prior use of an oxyimino-cephalosporin is a risk factor for infections caused by plasmid AmpC-producing Enterobacteriaceae.
    International journal of antimicrobial agents 04/2009; 34(1):38-43. DOI:10.1016/j.ijantimicag.2009.01.009 · 4.26 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study investigated the clinician response to the extended-spectrum beta-lactamase (ESBL) confirmation report generated by an automated detection system, MicroScan Walkaway. The study compared two cohorts (pre- and post-automated detection) of patients with an ESBL-producing Escherichia coli or Klebsiella species non-urinary infection over the period October 2001-December 2006. Acceptance of the report, as defined by the initiation of carbapenem therapy, was observed in 69.2% of the post-automated detection cohort (n=78) versus 20% in the pre-automated detection period (n=15) (P<or=0.001). The utilization of a carbapenem increased progressively over the course of the study. Moreover, the time to initiation of carbapenem therapy was reduced from 15.7+/-4.9 to 0.1+/-2.0 days (P<or=0.001) after implementation of this automated detection system. Overall, clinicians responded positively to the ESBL automated detection report, as gauged by the increased utilization of a carbapenem and the earlier initiation of appropriate therapy; however, reductions in length of stay and mortality were not observed in this infected population.
    Journal of Medical Microbiology 10/2008; 57(Pt 9):1147-51. DOI:10.1099/jmm.0.2008/000430-0 · 2.27 Impact Factor