Trivedi Mayuri, Patel Vipul, Soman Rajeev, Rodriguez Camilla, Singhal Tanu
Dept of Internal Medicine, P.D. Hinduja National Hospital and research centre, Mumbai.
J Assoc Physicians India. 2012 Aug;60:28-30.
In India where the prevalence of extended spectrum beta lactamase (ESBL) producing organisms among gram negative organisms is 60-70% and Ertapenem was unavailable at the beginning of this study, exclusive use of Group 2 Carbapenems (Imipenem and Meropenem) for treatment raises issues of cost and development of resistance. Therefore the role of non-Carbapenem alternatives, chiefly Betalactam + Betalactamase inhibitors (BL-BLI) was explored in this prospective observational study at a private tertiary care teaching hospital.
522 consecutive in door patients from the period between June 2006 to March 2007and June 2008 to December 2008, who had true infections with ESBL producing organisms were enrolled in the study. Antimicrobials were prescribed or changed by the treating physicians on the basis of the nature and severity of infection, the susceptibility of the organism and the affordability of the patient. Patients who received a Carbapenem at any time during treatment were considered in the Carbapenem group. Those who never received a Carbapenem at any time during treatment were considered in the non-Carbapenem group.
Of the 522 infections, 287 were urinary tract infections, 60 were skin structure infections, 60 were bacteremias, 55 were hospital acquired pneumonias, 31 were intra-abdominal infections and 29 were other infections. There were 351 E. coli, 119 K. pneumoniae, 23 K. oxytoca, 16 Enterobacter aerogenes, 5 Kozoanae, 4 Enterobacter agglomerans, 3 Citrobacter freundi, 1 E. cloacae, 1 Enterobacterspp. and 1 Morgenella morganii isolates. Clinical outcomes were available for 486 patients. 339 patients who were in the non-Carbapenem group and who might have had less serious infections had a clinical success rate of 79.6%. 147 patients who were in the Carbapenem group and who might have had more serious infections had a clinical success rate of 85.71%.
It is possible to successfully treat at least the less serious infections due to ESBL producing gram negative organisms with non-Carbapenem antimicrobials. This will not compromise outcomes but will likely result in restricting the use of Carbapenems which may help preserve their efficacy against increasingly resistant organisms.
在印度,革兰氏阴性菌中产超广谱β-内酰胺酶(ESBL)的微生物患病率为60%-70%,且在本研究开始时厄他培南无法获取,仅使用2类碳青霉烯类药物(亚胺培南和美罗培南)进行治疗会引发成本及耐药性产生的问题。因此,在一家私立三级护理教学医院开展的这项前瞻性观察性研究中,探讨了非碳青霉烯类替代药物的作用,主要是β-内酰胺类+β-内酰胺酶抑制剂(BL-BLI)。
纳入2006年6月至2007年3月以及2008年6月至2008年12月期间连续收治的522例院内患者,这些患者确诊感染产ESBL的微生物。治疗医生根据感染的性质和严重程度、微生物的敏感性以及患者的经济承受能力来开具或更换抗菌药物。在治疗期间任何时间接受过碳青霉烯类药物治疗的患者被纳入碳青霉烯类组。在治疗期间任何时间从未接受过碳青霉烯类药物治疗的患者被纳入非碳青霉烯类组。
在这522例感染中,287例为尿路感染,60例为皮肤及结构感染,60例为菌血症,55例为医院获得性肺炎,31例为腹腔内感染,29例为其他感染。分离出351株大肠杆菌、119株肺炎克雷伯菌、23株产酸克雷伯菌、16株产气肠杆菌、5株科泽氏菌、4株聚团肠杆菌、3株弗氏柠檬酸杆菌、1株阴沟肠杆菌、1株肠杆菌属细菌以及1株摩根摩根菌。486例患者有临床结局数据。非碳青霉烯类组中339例可能感染不太严重的患者临床成功率为79.6%。碳青霉烯类组中147例可能感染较严重的患者临床成功率为85.71%。
使用非碳青霉烯类抗菌药物成功治疗至少由产ESBL革兰氏阴性菌引起的不太严重的感染是有可能的。这不会影响治疗效果,但可能会限制碳青霉烯类药物的使用,这可能有助于保持其对耐药性日益增强的微生物的疗效。