Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
Int J Antimicrob Agents. 2021 Feb;57(2):106250. doi: 10.1016/j.ijantimicag.2020.106250. Epub 2020 Nov 29.
The application of cefepime breakpoint for carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteraemia has not been explored. Adult cases of monomicrobial bloodstream infection (BSI) caused by cefepime-susceptible [minimum inhibitory concentration (MIC) ≤8 mg/L] K. pneumoniae isolates with carbapenem resistance between 2010 and 2015 were reviewed. Patients treated with cefepime were compared with those treated by other active agents using a propensity score-matched analysis to assess therapeutic effectiveness. The primary endpoint was 30-day crude mortality. A total of 114 patients experienced cefepime-susceptible CRKP bacteraemia and 40 (35.1%) died during hospitalisation. A total of 33 patients (28.9%) received cefepime therapy. Fifteen patients (13.2%) had BSI due to carbapenemase-producing isolates, and 86.7% (13/15) of carbapenemase-producing isolates were classified as cefepime susceptible dose-dependent (SDD). In the multivariate logistic regression analysis, 30-day mortality was independently associated with the presence of a critical illness [adjusted odds ratio (aOR) = 12.89, 95% confidence interval (CI) 3.88-42.83; P < 0.001], pneumonia (aOR = 5.97, 95% CI 1.65-21.76; P = 0.007) and rapidly fatal underlying disease (aOR = 6.43, 95% CI 1.30-31.09; P = 0.02). In contrast, cefepime-based therapy (aOR = 0.03, 95% CI 0.003-0.38; P = 0.006) and combination therapy (aOR = 0.09, 95% CI 0.02-0.36; P = 0.001) were protective against a fatal outcome. Based on current breakpoints for Enterobacterales, cefepime therapy was not associated with an unfavourable outcome for CRKP BSI with MIC-based dosing strategies. However, the susceptibility result of SDD to cefepime should alert clinicians for possible therapeutic failure.
头孢吡肟折点在碳青霉烯类耐药肺炎克雷伯菌（CRKP）菌血症中的应用尚未得到探索。本研究回顾了 2010 年至 2015 年间，由对头孢吡肟敏感（最低抑菌浓度[MIC]≤8mg/L）、但对碳青霉烯类药物耐药的肺炎克雷伯菌引起的单一致病菌血症患者。采用倾向性评分匹配分析比较了接受头孢吡肟治疗的患者与接受其他有效药物治疗的患者，以评估治疗效果。主要终点为 30 天粗死亡率。共有 114 例患者发生头孢吡肟敏感 CRKP 菌血症，住院期间 40 例（35.1%）死亡。共 33 例（28.9%）患者接受了头孢吡肟治疗。15 例（13.2%）患者发生了产碳青霉烯酶分离株引起的菌血症，其中 86.7%（13/15）的产碳青霉烯酶分离株被归类为头孢吡肟敏感剂量依赖性（SDD）。多变量逻辑回归分析显示，30 天死亡率与重症疾病的存在独立相关（调整后的优势比[aOR]为 12.89，95%置信区间[CI]为 3.88-42.83；P<0.001）、肺炎（aOR 为 5.97，95%CI 为 1.65-21.76；P=0.007）和快速致命的基础疾病（aOR 为 6.43，95%CI 为 1.30-31.09；P=0.02）。相反，头孢吡肟为基础的治疗（aOR 为 0.03，95%CI 为 0.003-0.38；P=0.006）和联合治疗（aOR 为 0.09，95%CI 为 0.02-0.36；P=0.001）对致命结局具有保护作用。基于目前肠杆菌科的折点，基于 MIC 剂量策略的头孢吡肟治疗与 CRKP 菌血症的不良结局无关。然而，对头孢吡肟 SDD 的敏感性结果应提醒临床医生可能存在治疗失败的风险。
