Yang Chih-Chao, Wu Chien-Hsing, Lee Chien-Te, Liu Han-Tsung, Chen Jin-Bor, Chiu Chien-Hua, Chen Chih-Hung, Chuang Feng-Rong
Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City 833, Taiwan.
Division of Trauma and Emergency Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
Int J Infect Dis. 2014 Nov;28:3-7. doi: 10.1016/j.ijid.2014.07.012. Epub 2014 Sep 6.
In the face of increasing treatment options for extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) hemodialysis (HD) access-related bacteremia, the difference in clinical effectiveness between ertapenem and flomoxef remains unclear. We conducted this retrospective study to determine their efficacies and treatment outcomes.
Patients on maintenance HD with fistula-, graft-, or catheter-related ESBL-Kp bacteremia were enrolled. Data related to clinical features and antibiotic treatments were collected. Outcome was determined by mortality resulting from bacteremia during the 14-day period after the collection of the first positive blood culture for flomoxef-susceptible ESBL-Kp.
The 64 patients studied had severe septicemia as determined by the Pitt bacteremia score; 50% (32/64) were in the intensive care unit (ICU) at the time of bacteremia. Old age (>65 years; 57.8%), malnutrition (albumin<3.5g/dl; 92.2%), a history of severe illnesses (defined by shock, intubation, or ICU stay; 82.5%), and prolonged hospitalization prior to the onset of bacteremia (>30 days; 75%) were also highly prevalent. The study population comprised nine fistula-, 10 graft-, and 45 HD catheter-related bacteremia cases, and the mortality rate was high (38/64, 59.4%). The mortality rate was significantly higher in the flomoxef treatment group than in the ertapenem treatment group (22/30, 73% vs. 16/34, 47%, p<0.05). Among patients with catheter-related bacteremia, multivariate analyses revealed that flomoxef use (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.34-35.17) and Pitt bacteremia score (OR 4.37, 95% CI 1.28-5.26) were independently associated with mortality.
In accordance with our previous study, our results have demonstrated the inferiority of flomoxef to carbapenems in the treatment of HD access-related ESBL-Kp bacteremia and provide an insight into the possibility of using ertapenem rather than flomoxef as an initial or de-escalating therapy for infections caused by ESBL-producing bacteria.
面对产超广谱β-内酰胺酶肺炎克雷伯菌（ESBL-Kp）所致血液透析（HD）通路相关菌血症的治疗选择日益增多，厄他培南与氟莫西之间临床疗效的差异仍不明确。我们开展这项回顾性研究以确定它们的疗效及治疗结果。
纳入维持性HD且发生与动静脉内瘘、移植物或导管相关的ESBL-Kp菌血症的患者。收集与临床特征及抗生素治疗相关的数据。结局通过首次血培养出对氟莫西敏感的ESBL-Kp后14天内菌血症导致的死亡率来确定。
根据皮特菌血症评分，所研究的64例患者存在严重败血症；菌血症发生时50%（32/64）的患者在重症监护病房（ICU）。高龄（>65岁；57.8%）、营养不良（白蛋白<3.5g/dl；92.2%）、有严重疾病史（定义为休克、插管或入住ICU；82.5%）以及菌血症发生前住院时间延长（>30天；75%）也很常见。研究人群包括9例与动静脉内瘘相关、10例与移植物相关以及45例与HD导管相关的菌血症病例，死亡率很高（38/64，59.4%）。氟莫西治疗组的死亡率显著高于厄他培南治疗组（22/30，73%对16/34，47%，p<0.05）。在导管相关菌血症患者中，多因素分析显示使用氟莫西（比值比（OR）2.52，95%置信区间（CI）1.34 - 35.17）和皮特菌血症评分（OR 4.37，95%CI 1.28 - 5.26）与死亡率独立相关。
与我们之前的研究一致，我们的结果表明在治疗HD通路相关ESBL-Kp菌血症方面，氟莫西劣于碳青霉烯类药物，并为使用厄他培南而非氟莫西作为产ESBL细菌所致感染的初始或降阶梯治疗的可能性提供了见解。
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