Lim Chee Loon, Spelman Denis
Department of Medicine, Infectious Diseases Unit, Sungai Buloh Hospital, Selangor, 47000, Malaysia.
Department of Infectious Diseases, Microbiology Unit, Alfred Hospital, Melbourne, 3004, Australia.
Infect Dis Health. 2019 Aug;24(3):124-133. doi: 10.1016/j.idh.2019.02.001. Epub 2019 Mar 28.
Treatment of ESBL- and AmpC-producing Enterobacteriaceae bacteremia is often complicated by lack of appropriate antibiotics. We aimed to determine the predictors of mortality and impact of empirical antibiotics.
A retrospective observational study was performed on consecutive adult cases of ESBL and AmpC bacteremia at the Alfred Hospital from 2014 through April 2018.
Among 110 patients with ESBL (88.2%) and AmpC (14.5%) bacteremia episodes, 96.4% had comorbidities such as hematological malignancy (30%). Approximately 45% were on immunosuppressive drugs, while 69% had recent antibiotic exposure. Over 84% of bacteremias were hospital acquired or healthcare associated. Urinary tract was the main source of infection (40%) with E. coli being the commonest organism (66.4%). The isolates were least resistant to gentamicin (21.8%), which was often appropriately used in empirical therapy. About 34% of patients presented with severe sepsis or shock. The 30-day mortality rate was 20% with no correlation with inappropriate empirical antibiotics (52%). There was no significant mortality difference between carbapenem use in empirical and definitive therapy. Respiratory source [OR 11.77, 95% CI 1.30-106.85; p = 0.03], severe sepsis or shock [OR 5.17, 95% CI 1.37-19.55; p = 0.02] and inappropriate definitive therapy [OR 27.93, 95%CI 3.69-211.35; p = 0.001] were independent predictors for mortality.
The choice and appropriateness of empirical therapy were not associated with mortality in ESBL and AmpC bacteremia. Prudent use of carbapenem is reasonable with gentamicin as alternative. Emphasis should be on prompt resuscitation in severe sepsis and early detection of ESBL and AmpC to facilitate appropriate switch to definitive therapy.
产超广谱β-内酰胺酶（ESBL）和AmpC酶的肠杆菌科细菌血症的治疗常常因缺乏合适的抗生素而变得复杂。我们旨在确定死亡率的预测因素以及经验性抗生素的影响。
对2014年至2018年4月在阿尔弗雷德医院连续收治的成年ESBL和AmpC细菌血症病例进行回顾性观察研究。
在110例发生ESBL（88.2%）和AmpC（14.5%）细菌血症的患者中，96.4%患有合并症，如血液系统恶性肿瘤（30%）。约45%的患者正在使用免疫抑制药物，而69%的患者近期有抗生素暴露史。超过84%的细菌血症是医院获得性或与医疗保健相关的。泌尿系统是主要感染源（40%），大肠杆菌是最常见的病原体（66.4%）。分离株对庆大霉素的耐药性最低（21.8%），庆大霉素在经验性治疗中经常被合理使用。约34%的患者出现严重脓毒症或休克。30天死亡率为20%，与不恰当的经验性抗生素使用（52%）无关。在经验性治疗和确定性治疗中使用碳青霉烯类药物的死亡率无显著差异。呼吸道感染源[比值比（OR）11.77，95%置信区间（CI）1.30 - 106.85；p = 0.03]、严重脓毒症或休克[OR 5.17，95% CI 1.37 - 19.55；p = 0.02]以及不恰当的确定性治疗[OR 27.93，95% CI 3.69 - 211.35；p = 0.001]是死亡率的独立预测因素。
在ESBL和AmpC细菌血症中，经验性治疗的选择和恰当性与死亡率无关。谨慎使用碳青霉烯类药物并以庆大霉素作为替代是合理的。应重点关注严重脓毒症的及时复苏以及ESBL和AmpC的早期检测，以便及时转为恰当的确定性治疗。
