Title : Exploring non-carbapenem options for ESBL-producing Enterobacteriaceae bacteremia in emergency room: Focusing on Piperacillin-tazobactam
Abstract:
Background: In emergency room settings, the management of bacteremia caused by extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae (ESBL-E) is critical. Traditionally, carbapenems are the recommended treatment, but their use raises concerns about resistance. This study evaluates the effectiveness of non-carbapenem options, specifically piperacillin/tazobactam, for treating ESBL-E bacteremia in patients with lower acute severity.
Methods: We conducted a retrospective case-control study, including a cohort of patients with documented ESBL-E bacteremia from January 2021 to December 2021 in a single teaching hospital in Republic of Korea. Total 527 adults (aged 18 years or older) with Enterobacteriaceae bacteremia were enrolled into the study. Patients were excluded if they were infected with the same species (or ESBL-E) 3 months prior to the current positive result or if two or more species were identified within a specimen, including blood. Based on the exclusion criteria, 118 patients with ESBL-E bacteremia were included. Patients were divided into two groups based on the choice of antimicrobial therapy: non-carbapenem or carbapenem in emergency room. Antimicrobial susceptibility and phenotypic ESBL-E identification were tested using the Vitek 2 system (BioMérieux). The primary outcome was defined as same species isolation with the initial isolates from blood culture at two to five days after starting definitive antimicrobial drug maintenance, or relapesed fever, or deterioration of the clinical course which lead to change in antimicrobials five days after maintaining definitive antimicrobials, and the secondary outcome was 30-day mortality.
Results: Of 118 patients with ESBL-E bacteremia, 54 received non-carbapenem drugs (NCG) and 64 received carbapenems (CG). Among all patients, 54 (45.8%) were men, with a mean age of 71.1 years (± 11.6). The overall 30-day inpatient mortality was 16.1%. There was no significant difference in the primary outcome of treatment failure between the NCG and CG (16.7% vs. 18.8%, p=0.65). The secondary outcome of 30-day mortality occurred in eight and 11 patients in the NCG and the CG (14.8% vs. 17.2%, p=0.63). Additionally, based on the results of Cox regression analysis, there was no significant difference in the primary outcome of treatment failure between the NCG an CG (harad ratio [HR]=1.32; 95% confidence interval [CI]: 0.55–3.17, p=0.54), and there was no the secondary outcome of 30-day mortality in the NCG and the CG (HR=1.75; 95% CI: 0.51–6.05, p=0.38). In multivariate regression analysis, there were significant differences in treatment failure in the prior antimicrobial therapy within 30 days and extra-urinary tract infection. However, there was no significantly difference in the other variables including choice of non-carbapenem antimicrobial drugs.
Conclusion: In emergency room, non-carbapenem antimicrobials such as piperacillin/tazobactam are viable for patients with less severe ESBL-E bacteremia, potentially reducing reliance on carbapenems and preserving their efficacy for more critical cases in Republic of Korea.
