title: Cefepime Therapy for Monomicrobial Enterobacter cloacae Bacteremia: Unfavorable Outcomes in Patients Infected by Cefepime-Susceptible Dose-Dependent Isolates.
abstract: A new category of cefepime susceptibility, susceptible dose dependent (SDD), for Enterobacteriaceae, has been suggested to maximize its clinical use. However, clinical evidence supporting such a therapeutic strategy is limited. A retrospective study of 305 adults with monomicrobial Enterobacter cloacae bacteremia at a medical center from 2008 to 2012 was conducted. The patients definitively treated with in vitro active cefepime (cases) were compared with those treated with a carbapenem (controls) to assess therapeutic effectiveness. The 30-day crude mortality rate is the primary endpoint, and clinical prognostic factors are assessed. Of 144 patients receiving definitive cefepime or carbapenem therapy, there were no significant differences in terms of age, sex, comorbidity, source of bacteremia, disease severity, or 30-day mortality (26.4% versus 22.2%; P = 0.7) among those treated with cefepime (n = 72) or a carbapenem (n = 72). In the multivariate analysis, the presence of critical illness, rapidly fatal underlying disease, extended-spectrum beta-lactamase (ESBL) producers, and cefepime-SDD (cefepime MIC, 4 to 8 μg/ml) isolates was independently associated with 30-day mortality. Moreover, those infected by cefepime-SDD isolates with definitive cefepime therapy had a higher mortality rate than those treated with a carbapenem (5/7 [71.4%], versus 2/11 [18.2%]; P = 0.045). Cefepime is one of the therapeutic alternatives for cefepime-susceptible E. cloacae bacteremia but is inefficient for cases of cefepime-SDD E. cloacae bacteremia compared with carbapenem therapy.
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
authors.forename: Nan-Yao
authors.initials: NY
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
authors.forename: Ching-Chi
authors.initials: CC
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
authors.forename: Chia-Wen
authors.initials: CW
authors.lastname: Li
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
authors.forename: Ming-Chi
authors.initials: MC
authors.lastname: Li
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
authors.forename: Po-Lin
authors.initials: PL
authors.lastname: Chen
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
authors.forename: Chia-Ming
authors.initials: CM
authors.lastname: Chang
authors.affiliation: Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan winston3415@gmail.com.
authors.forename: Wen-Chien
authors.initials: WC
authors.lastname: Ko
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D015780:Carbapenems / Q000627:therapeutic use*; D000077723:Cefepime; D002511:Cephalosporins / Q000627:therapeutic use*; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D016972:Enterobacter cloacae / Q000187:drug effects* / Q000235:genetics / Q000378:metabolism; D004756:Enterobacteriaceae Infections / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D005260:Female; D015870:Gene Expression; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000150:complications / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D018440:beta-Lactam Resistance / Q000235:genetics; D001618:beta-Lactamases / Q000235:genetics / Q000378:metabolism
chemical_list: D000900:Anti-Bacterial Agents; D015780:Carbapenems; D002511:Cephalosporins; D000077723:Cefepime; D001618:beta-Lactamases