Clinical StudiesCarbapenems and piperacillin/tazobactam for the treatment of bacteremia caused by extended-spectrum β-lactamase–producing Proteus mirabilis
Introduction
Proteus mirabilis, a member of the Enterobacteriaceae family, is a common cause of community- and healthcare-associated infections, including urinary tract infection and bacteremia (Chen et al., 2012). The prevalence of extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae isolates, although varied across in different geographic regions, increased worldwide in recent years (Lee et al., 2012, Liu et al., 2012, Sheng et al., 2013, Wang et al., 2011). Patients with infections caused by such pathogens were associated with delay in appropriate antimicrobial therapy due to multiple drug resistance and subsequently increased risks of clinical failure and mortality (Endimiani et al., 2005, Lee et al., 2012, Tumbarello et al., 2007, Wang et al., 2011). Cephalosporin therapy for infections due to ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Klebsiella oxytoca has been associated with clinical failure and increased mortality. Therefore, the Clinical and Laboratory Standards Institute (CLSI) had recommended reporting ESBL-producing E. coli or Klebsiella isolates as being resistant to all penicillins, cephalosporins, and aztreonam (Gavin et al., 2006, Peterson, 2008). The rationale behind the recommendation of carbapenem therapy for all ESBL-producer infections, however, has been based solely on limited clinical experiences (Peterson, 2008, Rupp and Fey, 2003). Despite the CLSI recommendation that ESBL-producing isolates could be reported as being susceptible to β-lactam/β-lactamase inhibitors, many experts preferred carbapenems, but not β-lactam/β-lactamase inhibitors, to treat ESBL-producer infections (Gavin et al., 2006, Peterson, 2008). However, the increased carbapenem prescriptions have been associated with the emergence of carbapenem-resistant Enterobacteriaceae (CDC, 2013). Other antimicrobial agents, such as ampicillin/sulbactam, cefoperazone/sulbactam, or piperacillin/tazobactam, may be the alternative agents for ESBL-producing Enterobacteriaceae infections. Several studies had addressed the clinical role of piperacillin/tazobactam therapy for ESBL-producing Enterobacteriaceae infections (Gavin et al., 2006, Peterson, 2008), but no consensus was made. The aim of this study was to evaluate clinical outcome of adults with ESBL-producing P. mirabilis bacteremia treated by piperacillin/tazobactam or a carbapenem, in correlation with the MIC of treatment drug for the corresponding isolate.
Section snippets
Study design and settings
This retrospective study was conducted at 5 hospitals in Taiwan, including National Taiwan University Hospital and Far Eastern Memorial Hospital in northern Taiwan, National Cheng Kung University Hospital, Kaohsiung Medical University Hospital, and Chi-Mei Medical Center in southern Taiwan. During January 2005 to December 2012, adults (aged ≥18 years) with bacteremia due to ESBL-producing P. mirabilis were enrolled. Demographics, clinical characteristics, underlying disease, primary sources,
Results
During the study period, a total of 52 patients with ESBL-producing P. mirabilis bacteremia were identified. Five patients with incomplete clinical information were excluded. Eight P. mirabilis isolates from 8 patients were not preserved for further study. All patients received guideline concordant doses with appropriate renal function adjustment. For piperacillin-tazobactam, patients with creatinine clearance (Ccr) of >50 mL/min received 3.375–4.5 g every 6–8 hours, those with Ccr of 20–50
Discussion
Some studies had tried to identify the predictors of mortality in patients with ESBL-producing Enterobacteriaceae bacteremia (De Rosa et al., 2011, Tumbarello et al., 2007). However, ESBL-producing P. mirabilis was responsible for only 15.6%, 12.9% in the study population, respectively (De Rosa et al., 2011, Tumbarello et al., 2007). Other studies focused on the differences between ESBL-producing P. mirabilis bacteremia and non–ESBL-producer bacteremia (Endimiani et al., 2005, Kurihara et al.,
Competing interests
The authors declare that they have no competing interests.
Ethics statement
This study was approved by the Institutional Review Board of the National Taiwan University Hospital (NTUH IRB 201005033R).
References (26)
- et al.
Antimicrobial susceptibility of inpatient urinary tract isolates of gram-negative bacilli in the United States: results from the study for monitoring antimicrobial resistance trends (SMART) program: 2009–2011
Clin Ther
(2013) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987) - et al.
Proteus mirabilis urinary tract infection and bacteremia: risk factors, clinical presentation, and outcomes
J Microbiol Immunol Infect
(2012) - et al.
Occurrence and phenotypic detection of class A carbapenemases among Escherichia coli and Klebsiella pneumoniae blood isolates at a tertiary care center
J Microbiol Immunol Infect
(2013) - et al.
Carbapenem susceptibilities and non-susceptibility concordance to different carbapenems amongst clinically important Gram-negative bacteria isolated from intensive care units in Taiwan: results from the Surveillance of Multicentre Antimicrobial Resistance in Taiwan (SMART) in 2009
Int J Antimicrob Agents
(2013) - et al.
Clinical characteristics of urosepsis caused by extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumoniae and their emergence in the community
J Microbiol Immunol Infect
(2012) - et al.
Outcomes and characteristics of ertapenem-nonsusceptible Klebsiella pneumoniae bacteremia at a university hospital in Northern Taiwan: a matched case–control study
J Microbiol Immunol Infect
(2012) Antibiotic policy and prescribing strategies for therapy of extended-spectrum beta-lactamase-producing Enterobacteriaceae: the role of piperacillin-tazobactam
Clin Microbiol Infect
(2008)- et al.
Clinical manifestations and prognostic factors in cancer patients with bacteremia due to extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumoniae
J Microbiol Immunol Infect
(2011) Vital signs: carbapenem-resistant Enterobacteriaceae
MMWR Morb Mortal Wkly Rep
(2013)