Alfa Institute of Biomedical Sciences, 9 Neapoleos St. 151 23 Marousi, Athens, Greece.
J Antimicrob Chemother. 2012 Dec;67(12):2793-803. doi: 10.1093/jac/dks301. Epub 2012 Aug 21.
To study the comparative mortality associated with carbapenems and alternative antibiotics for the treatment of patients with extended-spectrum β-lactamase (ESBL)-positive Enterobacteriaceae bacteraemia.
We searched systematically PubMed and Scopus databases for studies providing data for mortality among patients treated with carbapenems, β-lactam/β-lactamase inhibitor combinations (BL/BLIs) or non-BL/BLIs (mainly cephalosporins and fluoroquinolones), preferably as monotherapy. Studies focusing on patients of all ages with community- and healthcare-associated bacteraemia were eligible. Data were pooled using the technique of meta-analysis.
Twenty-one articles, studying 1584 patients, were included. Escherichia coli and Klebsiella pneumoniae were the most commonly studied bacteria. Delay in appropriate treatment up to 6 days was reported. Carbapenems were used mainly as definitive therapy. Carbapenems were associated with lower mortality than non- BL/BLIs for definitive [risk ratio (RR) 0.65, 95% CI 0.47-0.91] and empirical (RR 0.50, 95% CI 0.33-0.77) treatment. No statistically significant differences in mortality were found between carbapenems and BL/BLIs administered as definitive (RR 0.52, 95% 0.23-1.13) or empirical (RR 0.91, 95% CI 0.66-1.25) treatment. BL/BLIs were not associated with lower mortality than non-BL/BLIs administered either definitively (RR 1.59, 95% 0.83-3.06) or empirically (RR 0.82, 95% 0.48-1.41). Data regarding subgroups according to the setting, comorbidity and bacterial species could not be extracted.
Based on data from non-randomized studies, carbapenems may be considered the treatment of choice for empirical treatment of patients with ESBL-producing Enterobacteriaceae bacteraemia. The role of BL/BLIs should be further evaluated for definitive treatment. Further research should focus on faster identification of ESBL-positive pathogens and potential differences in the treatment of each bacterial species.
研究治疗产超广谱β-内酰胺酶（ESBL）肠杆菌科细菌血症患者时，碳青霉烯类药物与替代抗生素的死亡率比较。
我们系统地在 PubMed 和 Scopus 数据库中搜索了提供碳青霉烯类药物、β-内酰胺/β-内酰胺酶抑制剂组合（BL/BLIs）或非 BL/BLIs（主要是头孢菌素类和氟喹诺酮类）治疗患者死亡率数据的研究，最好是作为单药治疗。研究对象为所有年龄段的社区获得性和医院获得性菌血症患者。使用荟萃分析技术汇总数据。
共纳入 21 篇文章，涉及 1584 名患者。最常研究的细菌是大肠埃希菌和肺炎克雷伯菌。报道称，适当治疗的延迟时间长达 6 天。碳青霉烯类药物主要作为确定性治疗药物使用。碳青霉烯类药物与非 BL/BLIs 相比，在确定性治疗[风险比（RR）0.65，95%可信区间（CI）0.47-0.91]和经验性治疗（RR 0.50，95%CI 0.33-0.77）中死亡率较低。碳青霉烯类药物与 BL/BLIs 作为确定性（RR 0.52，95%0.23-1.13）或经验性（RR 0.91，95%CI 0.66-1.25）治疗的死亡率无统计学差异。BL/BLIs 与非 BL/BLIs 相比，在确定性治疗（RR 1.59，95%CI 0.83-3.06）或经验性治疗（RR 0.82，95%CI 0.48-1.41）中死亡率均未降低。无法提取按治疗环境、合并症和细菌种类分组的数据。
基于非随机研究数据，碳青霉烯类药物可被视为治疗产 ESBL 肠杆菌科细菌血症患者经验性治疗的首选药物。BL/BLIs 在确定性治疗中的作用需要进一步评估。进一步的研究应集中于更快地鉴定 ESBL 阳性病原体和治疗每种细菌的潜在差异。
