Journal Article

Cefepime Therapy for Monomicrobial Bacteremia Caused by Cefepime-Susceptible Extended-Spectrum Beta-Lactamase—Producing Enterobacteriaceae: MIC Matters

Lee, Ching-Chi, Hsueh, Po-Ren, Huang, Wei-Han, Tsui, Ko-Chung, Lee, Nan-Yao, Ko, Wen-Chien

2013

Overview

Background. Extended-spectrum ß-lactamase (ESBL)—producing Enterobacteriaceae isolates are important clinical pathogens. In addition, the efficacy of cefepime for such infections is controversial. Methods. We performed a retrospective study of monomicrobial bacteremia caused by ESBL producers at 2 medical centers between May 2002 and August 2007. The patients definitively treated with in vitro active cefepime (cases) were compared with those treated with a carbapenem (controls) in a propensity score—matched analysis to assess therapeutic effectiveness. The 30-day crude mortality is the primary endpoint. Results. A total of 178 patients were eligible for the study. Patients who received cefepime (n = 17) as definitive therapy were more likely to have a clinical failure (odds ratio [OR] 6.2; 95% confidence interval [CI], 1.7–22.5; P = .002), microbiological failure (OR 5.5; 95% CI, 1.3–25.6; P = .04), and 30-day mortality (OR 7.1; 95% CI, 2.5–20.3; P < .001) than those who received carbapenem therapy (n = 161). Multivariate regression revealed that a critical illness with a Pitt bacteremia score ≥4 points (OR 5.4; 95% CI, 1.4–20.9; P = .016), a rapidly fatal underlying disease (OR 4.4; 95% CI, 1.5–12.6; P = .006), and definitive cefepime therapy (OR 9.9; 95% CI, 2.8–31.9; P < .001) were independently associated with 30-day crude mortality. There were 17 case-control pairs in the propensity scores matched analysis. The survival analysis consistently found that individuals who received cefepime therapy had a lower survival rate (log-rank test, P = .016). Conclusions. Based on the current Clinical and Laboratory Standards Institute susceptible breakpoint of cefepime (minimum inhibitory concentration ≤8 μg/mL), cefepime definitive therapy is inferior to carbapenem therapy in treating patients with so-called cefepime-susceptible ESBL-producer bacteremia.

• Publisher: Oxford University Press
• Subject: Aged / Aged, 80 and over / Anti-Bacterial Agents - therapeutic use / Antibacterial agents / Antibiotics / Antibiotics. Antiinfectious agents. Antiparasitic agents / Antimicrobials / ARTICLES AND COMMENTARIES / Bacteremia / Bacteremia - drug therapy / Bacteremia - microbiology / Bacterial diseases / Bacterial infections / Bacterial sepsis / beta-Lactamases - metabolism / Biological and medical sciences / Carbapenems / Carbapenems - therapeutic use / Case-Control Studies / Cephalosporins - therapeutic use / Drug therapy / Enterobacteriaceae / Enterobacteriaceae - enzymology / Enterobacteriaceae Infections - drug therapy / Enterobacteriaceae Infections - microbiology / Enzymes / Female / Gram-negative bacteria / Health outcomes / Human bacterial diseases / Humans / Infections / Infectious diseases / Labor standards / Male / Medical sciences / Microbial sensitivity tests / Middle Aged / Mortality / Multivariate Analysis / Operating rooms / Pharmacology. Drug treatments / Retrospective Studies / Survival / Treatment Outcome