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Carbapenem use in extended-spectrum cephalosporin-resistant Enterobacterales infections in US hospitals and influence of IDSA guidance: a retrospective cohort study - 25/07/24

Doi : 10.1016/S1473-3099(24)00149-X 
Morgan K Walker, MD a, b, Guoqing Diao, PhD c, Sarah Warner, MPH a, b, Ahmed Babiker, MBBS d, Maniraj Neupane, MD a, b, Jeffrey R Strich, MD a, b, Christina Yek, MD a, b, , Sameer S Kadri, MD a, b, ,
for the

National Institutes of Health Antimicrobial Resistance Outcomes Research Initiative (NIH–ARORI)

a Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA 
b Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA 
c Department of Biostatistics, George Washington University, Washington, DC, USA 
d Emory University School of Medicine, Atlanta, GA, USA 

* Correspondence to: Dr Sameer S Kadri, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA Critical Care Medicine Department Clinical Center National Institutes of Health Bethesda MD 20892 USA

Summary

Background

Disparate and rapidly changing practice recommendations from major professional infectious diseases societies for managing non-severe infections caused by extended-spectrum β-lactamase-producing Enterobacterales might hamper carbapenem stewardship. We aimed to understand the real-world management of extended-spectrum cephalosporin-resistant (ECR) Enterobacterales infections in US hospitals and factors influencing preference for carbapenems over alternative treatments.

Methods

This retrospective cohort study included adults (aged ≥18 years) admitted to hospital with ECR Enterobacterales infections in the PINC AI database. Antibiotic regimens were assessed during empirical and targeted treatment periods and by infection severity and site. Likelihood of receiving targeted carbapenems over time and before or after initial release of the Infectious Diseases Society of America (IDSA) guidance on Sept 8, 2020, was established with generalised estimating equations controlling for patient, hospital, and temporal confounders.

Findings

Between Jan 1, 2018, and Dec 31, 2021, 30 041 inpatient encounters with ECR Enterobacterales infections were identified at 168 US hospitals, of which 16 006 (53·3%) encounters were in women and 14 035 (46·7%) were in men, with a mean age of 67·3 years (SD 15·1). Although few patients received carbapenems empirically (5324 [17·7%] of 30 041), many did so as targeted treatment (17 518 [58·3%] of 30 041), including subgroups of patients without septic shock (3031 [45·6%] of 6651) and patients with urinary tract infections without septic shock (1845 [46·8%] of 3943) in whom specific narrower-spectrum alternatives were active. Transitions from non-carbapenem to carbapenem antibiotics occurred most often on the day that the ECR phenotype was reported, regardless of illness severity. Carbapenems were the predominant choice to treat ECR Enterobacterales infections over time (adjusted odds ratio 1·00 [95% CI 1·00–1·00]), with no additional immediate change (1·07 [0·95–1·20]) or sustained change (0·99 [0·98–1·00]) after IDSA guidance release.

Interpretation

High carbapenem use in targeting non-severe ECR Enterobacterales infections in US hospitals predates 2020 IDSA guidance and has persisted thereafter. Efforts to increase awareness and implementation of recommendations among clinicians to use carbapenem-sparing alternatives in ECR Enterobacterales infections might decrease global carbapenem selective pressure.

Funding

US National Institutes of Health Intramural Research Program, National Institute of Allergy and Infectious Diseases, and US Food and Drug Administration.

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Vol 24 - N° 8

P. 856-867 - août 2024 Retour au numéro
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