Use of Non-carbapenem Antibiotics in Patients with Urinary Tract Infection Caused by Extended-spectrum Beta-lactamase-producing Enterobacteriaceae

Yu Bin Seo; Young Keun Kim; Jacob Lee; Wonkeun Song

doi:10.14192/kjhaicp.2016.21.2.50

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Seo, Kim, Lee, and Song: Use of Non-carbapenem Antibiotics in Patients with Urinary Tract Infection Caused by Extended-spectrum Beta-lactamase-producing Enterobacteriaceae

Original Article

Korean J Healthc Assoc Infect Control Prev 2016;21(2):50-56.

Published online: 19 December 2016

DOI: https://doi.org/10.14192/kjhaicp.2016.21.2.50

Use of Non-carbapenem Antibiotics in Patients with Urinary Tract Infection Caused by Extended-spectrum Beta-lactamase-producing Enterobacteriaceae

Yu Bin Seo¹, Young Keun Kim², Jacob Lee¹, Wonkeun Song³

¹Division of Infectious Diseases, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea

²Division of Infectious Diseases, Department of Internal Medicine, Yonsei Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea

³Department of Laboratory Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea

Correspondence to: Jacob Lee, Division of Infectious Diseases, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Korea Tel: 02-820-5121, Fax: 02-6918-4222 E-mail: litjacob@chol.com

Received 14 March 2016 Revised 1 June 2016 Accepted 24 June 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Alternatives to carbapenem are increasingly needed to decrease the usage of carbapenem. We evaluated the possibility of using non-carbapenem antibiotics against urinary tract infections (UTI) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE).

Methods

This retrospective study was performed at 2 university hospitals between October 2010 and December 2012. All diagnosed adult cases of ESBL-PE UTI were identified from the microbiological database. The subjects were divided into 3 groups based on the empirical antibiotic classes and susceptibility: carbapenem (C) group, susceptible non-carbapenem (SNC) group, and non-susceptible non-carbapenem (NSNC) group.

Results

A total of 84 patients were eligible for analysis. For empirical therapy, 41, 23, and 20 patients were included in the NSNC, SNC, and C empirical groups, respectively. During the empirical therapy, 7 patients (17.1%) in the NSNC group, 18 patients (78.3%) in the SNC group, and 19 patients (78.3%) in the C group experienced clinical improvement. No significant difference was observed between the SNC and C empirical groups (P=0.192). Severe sepsis or shock was the predictor of empirical SNC treatment failure (P=0.048). There was a tendency to use carbapenem as a definite therapy in cases of NSNC. In contrast, empirical SNC was maintained as a definite therapy.

Conclusion

SNC could be considered as an alternative to carbapenems for treating ESBL-PE UTI. This strategy might decrease the usage of carbapenem without clinical deterioration. However, it should be noted that SNC therapy may fail in the case of severe sepsis or shock.

Keywords: Carbapenem, Extended-spectrum beta-lactamase, Urinary tract infection

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Figure 1.

Flow chart describing the process for patient selection.

Table 1.

Characteristics of patients with urinary tract infectionscaused by extended-spectrum beta-lactamase-producing Enterobacteriaceae based on empirical antibiotic groups

		NSNC group (n=41)	SNC group (n=23)	C group (n=20)	P-value
Age, mean±SD, years		69.5±12.0	70.9±17.3	73.8±14.0	0.544
Gender, female, n (%)		31 (75.6)	15 (65.2)	13 (65.0)	0.575
Comorbidity, n (%)
	Diabetes mellitus	7 (17.1)	4 (17.4)	5 (25.0)	0.739
	Cerebrovascular accident	19 (46.3)	8 (34.8)	8 (40.0)	0.657
	Dementia	2 (4.9)	1 (4.3)	2 (10.0)	0.679
	Hemiplegia	5 (12.2)	3 (13.0)	0 (0)	0.250
	Myocardial infarction	2 (4.9)	0 (0)	1 (5.0)	0.556
	Congestive heart failure	1 (2.4)	3 (13.0)	0 (0)	0.083
	Chronic obstructive lung disease	1 (2.4)	1 (4.3)	0 (0)	0.647
	Chronic kidney disease	1 (2.4)	2 (8.7)	2 (10.0)	0.407
	Liver cirrhosis	2 (4.9)	2 (8.7)	1 (5.0)	0.611
	Malignancy	6 (14.6)	2 (8.7)	2 (10.0)	0.746
	None	6 (14.6)	3 (13.0)	0 (0)	0.203
Charlson comorbidity index, median (interquartile range)		5.0 (4.0-7.0)	5.0 (3.0-6.0)	5.0 (4.25-5.0)	0.546
ICU admission, n (%)		17 (41.5)	10 (43.5)	11 (55.0)	0.596
Severe sepsis or shock, n (%)		14 (34.1)	5 (21.7)	5 (25.0)	0.528
Uropathogen, n (%)					0.691
	Escherichia coli	29 (70.7)	18 (78.3)	14 (70.0)
	Klebsiella pneumoniae	8 (19.5)	2 (8.7)	4 (20.0)
	Proteus mirabilis	3 (7.3)	2 (8.7)	1 (5.0)
	Enterobacter cloacae	1 (2.4)	1 (4.3)	0 (0)
	Providencia	0 (0)	0 (0)	1 (5.0)

Abbreviations: NSNC, non-susceptible non-carbapenem; SNC, susceptible non-carbapenem; C, carbapenem.

Table 2.

Differences in clinical outcomes among empirical antibiotic groups

	NSNC group (n=41)	SNC group (n=23)	C group (n=20)	P-value
Clinical improvement, n (%)	7 (17.1)	18 (78.3)	19 (95.0)	＜0.001
Selection of carbapenem for definite therapy, n (%)	34 (82.9)	7 (30.4)	18 (90.0)	＜0.001
Selection of susceptible-non carbapenem for definite therapy, n (%)	7 (17.1)	16 (69.6)	2 (10.0)	＜0.001
Total duration of antibiotic therapy, mean±SD	14.4±3.7	11.9±5.5	10.7±3.6	0.005
28-day mortality, n (%)	1 (2.4)	1 (4.3)	2 (10.0)	0.426

Abbreviations: NSNC, non-susceptible non-carbapenem; SNC, susceptible non-carbapenem; C, carbapenem.

Table 3.

Factors associated with failure of empirical treatment for urinary tract infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae

Variable		Success group (n=44)	Failure group (n=40)	Univariate analysis		Multivariate analysis
Variable		Success group (n=44)	Failure group (n=40)	OR (95% CI)	P-value	OR (95% CI)	P-value
Age, mean±SD, years		71.3±15.6	70.5±12.3	…	0.803	…	…
Gender, female, n (%)		29 (65.9)	30 (75.0)	1.27 (0.74-2.19)	0.363	…	…
Charlson comorbidity index, median (interquartile range)		5.0 (4.0-5.0)	5.0 (4.25-7.0)	…	0.048	1.31 (0.92-1.89)	0.139
ICU admission, n (%)		17 (38.6)	21 (52.5)	1.76 (0.74-4.18)	0.202	…	…
Severe sepsis or shock, n (%)		7 (15.9)	17 (42.5)	3.91 (1.41-10.87)	0.007	8.04 (1.50-43.06)	0.015
Uropathogen, n (%)
	Escherichia coli	30 (68.2)	31 (77.5)	1.61 (0.61-4.27)	0.339	…	…
	Klebsiella pneumoniae	10 (22.7)	4 (10.0)	0.38 (0.11-1.32)	0.118	…	…
	Proteus mirabilis	2 (4.5)	4 (10.0)	2.33 (0.40-13.49)	0.418	…	…
	Enterobacter cloacae	1 (2.3)	1 (2.5)	1.10 (0.07-18.23)	1.000	…	…
	Providencia	1 (2.3)	0 (0)	…	1.000	…	…
Empirical use, n (%)
	NSNC	7 (15.9)	34 (85.0)	29.95 (9.15-98.03)	＜0.001	156.55 (14.06-1742.81)^*	＜0.001
	SNC	18 (40.9)	5 (12.5)	0.21 (0.07-0.63)	0.004	6.38 (0.59-69.27)^*	0.128
	C	19 (43.2)	1 (2.5)	0.03 (0.01-0.27)	＜0.001

Ellipses indicate not available, ^*compared with carbapenem.

Abbreviations: NSNC, non-susceptible non-carbapenem; SNC, susceptible non-carbapenem; C, carbapenem.

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