Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) infections: are carbapenem alternatives achievable in daily practice?
OBJECTIVE
To avoid the use of carbapenems, alternatives such as cephamycin, piperacillin-tazobactam, and others are suggested for the treatment of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) infections. The aim of this study was to evaluate the frequency and the feasibility of antimicrobial de-escalation for ESBL-PE-related infections.


METHODS
A prospective observational, bi centric cohort study was conducted. All patients with ESBL-PE infections were included. De-escalation was systematically suggested if patients were clinically stable and the isolate was susceptible to possible alternatives.


RESULTS
Seventy-nine patients were included: 36 (45.6%) were children, 27 (34.1%) were hospitalized in intensive care units, and 37 (47%) were immunocompromised. Urinary tract infections, pneumonia, and catheter-related bloodstream infections accounted for 45.6%, 19%, and 10%, respectively, of the cohort. Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae were the three most frequent causative organisms isolated. On day 5, 47 (59.2%) of the patients were still receiving carbapenems. Antimicrobial resistance (44.7%), infection relapse (26.9%), and clinical instability (19.2%) were the most important reasons for not prescribing alternatives. E. coli-related infections appeared to be a protective factor against maintaining the carbapenem prescription (odds ratio 0.11, 95% confidence interval 0.041-0.324; p=0.0013).


CONCLUSIONS
In clinical practice, less than 50% of patients with ESBL-PE-related infections were de-escalated after empirical treatment with carbapenems.
Université Paris Descartes, Hôpital Necker Enfants Malades, Service de Maladies Infectieuses et Tropicales, Paris, France; Groupe Hospitalier Paris Saint-Joseph, Equipe Mobile de Microbiologie Clinique, Paris, France.
B
B
Pilmis
Université Paris XII, Hôpital Henri Mondor, Unité de Contrôle Épidémiologique et Prévention de l'Infection, Créteil, France.
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T
Delory
Université Paris Descartes, Hôpital Cochin, Service de Médecine Interne, Paris, France.
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M
Groh
Université Paris Diderot, Hôpital Beaujon, Département d'Anesthésie-Réanimation, Clichy, France.
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E
Weiss
Université Paris XII, Hôpital Henri Mondor, Laboratoire de Bactériologie-Hygiène, Département de Virologie, Bactériologie-Hygiène, Parasitologie-Mycologie, Créteil, France.
A
A
Emirian
Université Paris Descartes, Hôpital Necker Enfants Malades, Laboratoire de Microbiologie, Paris, France.
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H
Lecuyer
Université Paris XII, Hôpital Henri Mondor, Unité de Contrôle Épidémiologique et Prévention de l'Infection, Créteil, France.
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Lesprit
Université d'Angers, Unité de Prévention et de Lutte Contre les Infections Nosocomiales, CHU d'Angers, 4 rue Larrey, 49000 Angers, France. Electronic address: JeanRalph.ZAHAR@chu-angers.fr.
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JR
Zahar
D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015780:Carbapenems / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D016972:Enterobacter cloacae / Q000302:isolation & purification; D004755:Enterobacteriaceae / Q000201:enzymology* / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000188:drug therapy* / Q000382:microbiology; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000188:drug therapy; D005260:Female; D006801:Humans; D007711:Klebsiella pneumoniae / Q000302:isolation & purification; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D055815:Young Adult; D001618:beta-Lactamases / Q000032:analysis*
D000900:Anti-Bacterial Agents; D015780:Carbapenems; D001618:beta-Lactamases
Carbapenem; De-escalation; Extended-spectrum beta-lactamase