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288 Impact of consolidative antimicrobial therapy on mortality in patients with blood stream infections (BSIs) due to extended spectrum β-lactamase-producing pathogens

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
Jennifer Veltman, MD , Wayne State University, Detroit Medical Center, Detroit, MI, Detroit, MI
Jing Zhao, Pharm, D , Detroit Medical Center,Wayne State University, Detroit, MI
Ryan Tansek, BS , Wayne State University, Detroit, MI
Dania Hatahet, MD , Detroit Medical Center,Wayne State University, Detroit, MI
Khawar Chaudry, BS , Detroit Medical Center, Wayne State University, Detroit, MI
Jason M. Pogue, Pharm, D , Detroit Medical Center, Wayne State University, Detroit, MI
Ashish Bhargava , Detroit Medical Center, Wayne State University, Detroit, MI
Ylinne Lynch, BS , Wayne State University, Detroit, MI
Dror Marchaim, MD , Detroit Medical Center, Wayne State University, Detroit, MI
George Alangaden, MD , Detroit Medical Center,Wayne State University, Detroit, MI
Keith S. Kaye, MD, MPH , Detroit Medical Center, Wayne State University, Detroit, MI
Teena Chopra, MD , Detroit Medical Center, Wayne State University, Detroit, MI
Background: Our group previously reported that among patients with BSI due to ESBLs, empiric carbapenem therapy was associated with a trend towards decreased mortality and empiric cefepime was associated with a trend towards increased mortality.

Objective: To study the impact of consolidative therapy with carbapenem and cefepime on outcomes of patients with BSI due to ESBLs.

Methods: A retrospective cohort study was conducted including patients admitted to 5 Detroit area hospitals 1/05 to 12/07. Chart review was conducted on patients who had BSIs due to ESBL-producing Klebsiella pneumoniae or Escherichia coli (ESBLs). Patient variables collected included demographics, comorbid conditions, empiric antimicrobial treatment, consolidative treatment and in-hospital mortality. Consolidative antibiotics were defined as antibiotics initiated from day 3 to day 7 after culture, where day 0 was the day of culture.  Logistic regression was used to identify independent predictors for in-hospital mortality.

Results: 145 patients with BSI due to ESBL were identified; 83% were Klebsiella sp. and 17% were E. coli.  Thirty five percent of the BSIs were catheter-related.  The mean age of the patients was 66 years, 51% were female and 79.3% were African-American.  The in-hospital mortality rate was 35 %( n=51).  In logistic regression, predictors of in-hospital mortality included: admission to intensive care unit (OR=2.14, 95% CI 0.96-4.76), central line present prior to positive culture (OR=2.13, 95%CI 0.70-6.45) presence of a rapidly fatal condition at the time of admission (OR=5.71,95%CI 2.36-13.8) and prior hospitalization(OR=1.75,95%CI .76-4.02).  54(37.2%) patients received either consolidative therapy with no notable activity against the ESBL pathogens.  76 (52.4%) patients received consolidative therapy with a carbapenem, 31(21.4%) patients received cefepime, and 15 (10.3) patients received both cefepime and a carbapenem.  When consolidative therapy was included in the multivariate model for mortality, neither cefipime (OR-0.8;CI- 0.34-2.29) nor carbapenems (OR-0.5;CI-0.25-1.21) were significantly associated with mortality.

Conclusions: The current study was of limited power to demonstrate an impact of consolidative antimicrobial therapy on mortality.  Although neither cabapenem nor cefepime consolidative therapy was associated with decreased mortality, there was a trend towards decreased mortality with carbapenems.