产碳青霉烯酶肺炎克雷伯菌和头孢他啶-阿维巴坦快速分子检测对碳青霉烯类耐药肠杆菌科菌血症患者结局的影响。
Impact of a Rapid Molecular Test for Klebsiella pneumoniae Carbapenemase and Ceftazidime-Avibactam Use on Outcomes After Bacteremia Caused by Carbapenem-Resistant Enterobacterales.
机构信息
Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.
Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.
出版信息
Clin Infect Dis. 2022 Dec 19;75(12):2066-2075. doi: 10.1093/cid/ciac354.
BACKGROUND
Patients with bacteremia due to carbapenem-resistant Enterobacterales (CRE) experience delays until appropriate therapy and high mortality rates. Rapid molecular diagnostics for carbapenemases and new β-lactam/β-lactamase inhibitors may improve outcomes.
METHODS
We conducted an observational study of patients with CRE bacteremia from 2016 to 2018 at 8 New York and New Jersey medical centers and assessed center-specific clinical microbiology practices. We compared time to receipt of active antimicrobial therapy and mortality between patients whose positive blood cultures underwent rapid molecular testing for the Klebsiella pneumoniae carbapenemase (KPC) gene (blaKPC) and patients whose cultures did not undergo this test. CRE isolates underwent antimicrobial susceptibility testing by broth microdilution and carbapenemase profiling by whole-genome sequencing. We also assessed outcomes when ceftazidime-avibactam and polymyxins were used as targeted therapies.
RESULTS
Of 137 patients with CRE bacteremia, 89 (65%) had a KPC-producing organism. Patients whose blood cultures underwent blaKPC PCR testing (n = 51) had shorter time until receipt of active therapy (median: 24 vs 50 hours; P = .009) compared with other patients (n = 86) and decreased 14-day (16% vs 37%; P = .007) and 30-day (24% vs 47%; P = .007) mortality. blaKPC PCR testing was associated with decreased 30-day mortality (adjusted odds ratio: .37; 95% CI: .16-.84) in an adjusted model. The 30-day mortality rate was 10% with ceftazidime-avibactam monotherapy and 31% with polymyxin monotherapy (P = .08).
CONCLUSIONS
In a KPC-endemic area, blaKPC PCR testing of positive blood cultures was associated with decreased time until appropriate therapy and decreased mortality for CRE bacteremia, and ceftazidime-avibactam is a reasonable first-line therapy for these infections.
背景
耐碳青霉烯类肠杆菌科（CRE）引起的菌血症患者在接受适当治疗方面存在延迟，且死亡率较高。快速的碳青霉烯酶和新型β-内酰胺/β-内酰胺酶抑制剂的分子诊断可能改善预后。
方法
我们对 2016 年至 2018 年在 8 家纽约和新泽西州医疗中心发生的 CRE 菌血症患者进行了一项观察性研究，并评估了各中心特定的临床微生物学实践。我们比较了接受快速分子检测产肺炎克雷伯菌碳青霉烯酶（KPC）基因（blaKPC）的血培养阳性患者和未接受该检测的患者接受积极抗菌治疗的时间以及死亡率。CRE 分离株通过肉汤微量稀释法进行抗微生物敏感性检测，通过全基因组测序进行碳青霉烯酶谱分析。我们还评估了头孢他啶-阿维巴坦和多黏菌素作为靶向治疗的结果。
结果
在 137 例 CRE 菌血症患者中，89 例（65%）为产 KPC 生物体。接受 blaKPC PCR 检测的血培养患者（n = 51）与其他患者（n = 86）相比，接受积极治疗的时间更短（中位数：24 小时 vs 50 小时；P =.009），14 天（16% vs 37%；P =.007）和 30 天（24% vs 47%；P =.007）死亡率降低。在调整模型中，blaKPC PCR 检测与 30 天死亡率降低相关（调整后的优势比：0.37；95%CI：0.16-0.84）。头孢他啶-阿维巴坦单药治疗的 30 天死亡率为 10%，多黏菌素单药治疗的 30 天死亡率为 31%（P =.08）。
结论
在 KPC 流行地区，对阳性血培养物进行 blaKPC PCR 检测可缩短获得适当治疗的时间，并降低 CRE 菌血症的死亡率，头孢他啶-阿维巴坦是这些感染的合理一线治疗药物。
Zotero 插件