Tamma Pranita D, Pierce Virginia M, Cosgrove Sara E, Lautenbach Ebbing, Harris Anthony, Rayapati Divya, Han Jennifer H
Division of Infectious Diseases, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.
Microbiology Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts.
Open Forum Infect Dis. 2018 Jun 8;5(6):ofy139. doi: 10.1093/ofid/ofy139. eCollection 2018 Jun.
In 2010, the Clinical Laboratory and Standards Institute recommended a 3-fold lowering of ceftriaxone breakpoints to 1 mcg/mL for . Supportive clinical data at the time were from fewer than 50 patients. We compared the clinical outcomes of adults with bloodstream infections treated with ceftriaxone compared with matched patients (with exact matching on ceftriaxone minimum inhibitory concentrations [MICs]) treated with extended-spectrum agents to determine if ceftriaxone breakpoints could be increased without negatively impacting patient outcomes.
A retrospective cohort study was conducted at 3 large academic medical centers and included patients with bacteremia with ceftriaxone MICs of 2 mcg/mL treated with ceftriaxone or extended-spectrum β-lactams (ie, cefepime, piperacillin/tazobactam, meropenem, or imipenem/cilastatin) between 2008 and 2014; 1:2 nearest neighbor propensity score matching was performed to estimate the odds of recurrent bacteremia and mortality within 30 days.
Propensity score matching yielded 108 patients in the ceftriaxone group and 216 patients in the extended-spectrum β-lactam group, with both groups well-balanced on demographics, preexisting medical conditions, severity of illness, source of bacteremia, and source control interventions. No difference in recurrent bacteremia (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.49-2.73) or mortality (OR, 1.27; 95% CI, 0.56-2.91) between the treatment groups was observed for patients with isolates with ceftriaxone MICs of 2 mcg/mL. Only 6 isolates (1.6%) with ceftriaxone MICs of 2 mcg/mL were extended-spectrum β-lactamase (ESBL)-producing.
Our findings suggest that patient outcomes are similar when receiving ceftriaxone vs extended-spectrum agents for the treatment of bloodstream infections with ceftriaxone MICs of 2 mcg/mL. This warrants consideration of adjusting the ceftriaxone susceptibility breakpoint from 1 to 2 mcg/mL, as a relatively small increase in the antibiotic breakpoint could have the potential to limit the use of large numbers of extended-spectrum antibiotic agents.
2010年，临床实验室标准协会建议将头孢曲松的折点降低3倍至1 mcg/mL用于……当时支持性的临床数据来自不到50名患者。我们比较了接受头孢曲松治疗的成人血流感染患者与接受广谱抗菌药物治疗的匹配患者（根据头孢曲松最低抑菌浓度[MIC]进行精确匹配）的临床结局，以确定头孢曲松折点是否可以提高而不对患者结局产生负面影响。
在3家大型学术医疗中心进行了一项回顾性队列研究，纳入了2008年至2014年间头孢曲松MIC为2 mcg/mL的菌血症患者，这些患者接受了头孢曲松或广谱β-内酰胺类药物（即头孢吡肟、哌拉西林/他唑巴坦、美罗培南或亚胺培南/西司他丁）治疗；进行1:2最近邻倾向评分匹配以估计30天内复发性菌血症和死亡率的几率。
倾向评分匹配产生了头孢曲松组108例患者和广谱β-内酰胺类药物组216例患者，两组在人口统计学、既往病史、疾病严重程度、菌血症来源和源头控制干预方面均衡良好。对于头孢曲松MIC为2 mcg/mL的分离株患者，治疗组之间在复发性菌血症（比值比[OR]，1.16；95%置信区间[CI]，0.49 - 2.73）或死亡率（OR，1.27；95% CI，0.56 - 2.91）方面未观察到差异。只有6株（1.6%）头孢曲松MIC为2 mcg/mL的分离株产超广谱β-内酰胺酶（ESBL）。
我们的研究结果表明，对于头孢曲松MIC为2 mcg/mL的血流感染患者，接受头孢曲松与接受广谱抗菌药物治疗时患者结局相似。这值得考虑将头孢曲松的药敏折点从1 mcg/mL调整至2 mcg/mL，因为抗生素折点相对较小的增加可能有潜力限制大量广谱抗生素药物的使用。
