Discrepancy between effects of carbapenems and flomoxef in treating nosocomial hemodialysis access-related bacteremia secondary to extended spectrum beta-lactamase producing klebsiella pneumoniae in patients on maintenance hemodialysis

BMC Infectious Diseases

Chien-Te Lee¹  Chien-Hsing Wu¹  Jin-Bor Chen¹  Chih-Hsiung Lee³  Chih-Hung Chen³  Feng-Rong Chuang¹  Shau-Hsuan Li²  Chih-Chao Yang¹ 

[1] Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Kaohsiung city, Niao Sung District, 833, Taiwan;Division of Hematology-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan;Division of General Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

关键词: Klebsiella pneumoniae;    Hemodialysis access;    Flomoxef;    Extended spectrum beta-lactamase;    Carbapenems;    Bacteremia;   

Others  :  1159702
DOI  :  10.1186/1471-2334-12-206

 received in 2011-07-29, accepted in 2012-08-31,  发布年份 2012

【 摘 要 】

Background

Hemodialysis (HD) patients are susceptible to extended spectrum beta-lactamase (ESBL)-producing bacterial infections. Because the optimal treatment and clinical significance of ESBL-producing Klebsiella pneumoniae (ESBL-Kp) HD access-related bacteremia remain unclear, we conducted this retrospective study to determine the clinical outcomes of patients treated with either flomoxef or a carbapenem.

Methods

The eligibility criterion was fistula or graft- or catheter- related ESBL-Kp bacteremia in patients on maintenance HD. The clinical characteristics and antibiotic management were analyzed. Outcome was determined by mortality resulting from bacteremia during the 14‐day period after the first positive blood culture for flomoxef-susceptible ESBL-Kp.

Results

The 57 patients studied were predominantly elderly, malnourished, with a history of severe illnesses and broad-spectrum antibiotic use before the onset of bacteremia, and with severe septicemia as determined by the Pitt bacteremia score (PBS). The study population comprised 7 fistula, 8 graft, and 42 HD catheter-related bacteremia (CRB) cases, and the mortality rate was high (36/57, 63.2%) in these 57 patients. Of 42 patients with CRB, those in the deceased group (27/42, 64.3%) had significantly lower levels of serum albumin, longer prior hospital stay and duration of catheter-dependent HD, and higher PBS than patients in the survived group. Failure to receive effective antibiotics (flomoxef or a carbapenem) within 5 days after onset of bacteremia and treatment with flomoxef both significantly contributed to higher mortality. Multivariate analyses revealed that flomoxef use, PBS, and catheter-dependent HD >30 days were independently associated with increased mortality (OR, 3.52; 95% CI, 1.19–58.17, OR, 2.92; 95% CI, 1.36–6.26 and OR, 5.73; 95% CI, 1.21–63.2, respectively).

Conclusions

Considering the high mortality rate, ESBL-Kp should be recognized as a possible pathogen in patients on maintenance HD at high risk of acquiring HD access infections associated with ESBL-producing bacteria. Carbapenems rather than flomoxef should be the therapy of choice in these critically vulnerable patients.

【 授权许可】

   
2012 Yang et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Allon M: Dialysis catheter-related bacteraemia: treatment and prophylaxis. Am J Kidney Dis 2004, 44:779-791.
• [2]Nassar GM, Ayus JC: Infectious complications of the hemodialysis access. Kidney Int 2001, 60:1-13.
• [3]Bradford PA: Extended-spectrum beta-lactamases in the 21st century: characterization, epidemiology, and detection of this important resistance threat. Clin Microbiol Rev 2001, 14:933-951.
• [4]Rupp ME, Fey PD: Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae: considerations for diagnosis, prevention and drug treatment. Drugs 2003, 63:353-365.
• [5]Paterson DL: Recommendation for treatment of severe infections caused by Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs). Clin Microbiol Infect 2000, 6:460-463.
• [6]Jacoby GA, Carreras I: Activities of beta-lactam antibiotics against Escherichia coli strains producing extended spectrumβ-lactamases. Antimicrob Agents Chemother 1990, 34:858-862.
• [7]Pitout JD, Laupland KB: Extended-spectrum beta-lactamase-producing Enterobacteriaceae: an emerging public-health concern. Lancet Infect Dis 2008, 8:159-166.
• [8]Yan JJ, Wu SM, Tsai SH, Wu JJ, Su IJ: Prevalence of SHV-12 among clinical isolates of Klebsiella pneumoniae producing extended-spectrum beta-lactamases and identification of a novel AmpC enzyme (CMY-8) in Southern Taiwan. Antimicrob Agents Chemother 2000, 44:1438-1442.
• [9]Lee CH, Su LH, Tang YF, Liu JW: Treatment of ESBL-producing Klebsiella pneumoniae bacteraemia with carbapenems or flomoxef: a retrospective study and laboratory analysis of the isolates. J Antimicrob Chemother 2006, 58:1074-1077.
• [10]Paterson DL, Bonomo RA: Extended-spectrum beta-lactamases: a clinical update. Clin Microbiol Rev 2005, 18:657-686.
• [11]National Committee for Clinical Laboratory Standards: Performance Standards for Antimicrobial Susceptibility Testing—Eleventh Informational Supplements: Approved Standard M100-S10. NCCLS, Villanova, PA, USA; 2001.
• [12]Grimm H: Interpretive criteria of antimicrobial disk susceptibility tests with flomoxef. Infection 1991, 19(Suppl 5):S258-263.
• [13]Kim BN, Woo JH, Kim MN, Ryu J, Kim YS: Clinical implications of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae bacteremia. J Hosp Infect 2002, 52:99-106.
• [14]Paterson DL, Ko WC, Von Gottberg A, et al.: Outcome of cephalosporin treatment for serious infections due to apparently susceptible organisms producing extended-spectrum beta-lactamases: implications for the clinical microbiology laboratory. J Clin Microbiol 2001, 39:2206-2212.
• [15]Thomson KS, Moland ES: Cefepime, piperacillin-tazobactam, and the inoculum effect in tests with extended-spectrum beta-lactamase-producing Enterobacteriaceae. Antimicrob Agents Chemother 2001, 45:3548-3554.
• [16]Paterson DL, Mulazimoglu L, Casellas JM, et al.: Epidemiology of ciprofloxacin resistance and its relationship to extended-spectrum beta-lactamase production in Klebsiella pneumoniae isolates causing bacteremia. Clin Infect Dis 2000, 30:473-478.
• [17]Jacoby GA, Sutton L: Properties of plasmids responsible for production of extended-spectrum β-lactamases. Antimicrob Agents Chemother 1991, 35:164-169.
• [18]Go ES, Urban C, Burns J, et al.: Clinical and molecular epidemiology of Acinetobacter infections sensitive only to polymyxin B and sulbactam. Lancet 1994, 344:1329-1332.
• [19]Rahal JJ, Urban C, Horn D, et al.: Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998, 280:1233-1237.
• [20]Sanyal SC, Mokaddas EM: The increase in carbapenem use and emergence of Stenotrophomonas maltophilia as an important nosocomial pathogen. J Chemother 1999, 11:28-33.
• [21]Bauernfeind A, Schweighart S, Eberlein E, Jungwirth R: In vitro activity and stability against novel beta-lactamases of investigational beta-lactams (cefepime, cefpirome, flomoxef, SCE2787 and piperacillin plus tazobactam) in comparison with established compounds (cefotaxime, latamoxef and piperacillin). Infection 1991, 19(Suppl 5):264-275.
• [22]Paterson DL, Ko WC, Von Gottberg A, et al.: Antibiotic therapy for Klebsiella pneumoniae bacteremia: implications of production of extended-spectrum beta-lactamases. Clin Infect Dis 2004, 39:31-37.