Geographical variation in therapy for bloodstream infections due to multidrug-resistant Enterobacteriaceae: a post-hoc analysis of the INCREMENT study

• Published in: International journal of antimicrobial agents Vol. 50; no. 5; pp. 664 - 672
• Main Authors: Harris, Patrick N.A., Pezzani, M. Diletta, Gutiérrez-Gutiérrez, Belén, Viale, Pierluigi, Hsueh, Po-Ren, Ruiz-Garbajosa, Patricia, Venditti, Mario, Tumbarello, Mario, Navarro-Francisco, Carolina, Calbo, Esther, Akova, Murat, Giamarellou, Helen, Oliver, Antonio, Almirante, Benito, Gasch, Oriol, Martínez-Martínez, Luis, Schwaber, Mitchell J., Daikos, George, Pitout, Johann, Peña, Carmen, Hernández-Torres, Alicia, Doi, Yohei, Pérez, Federico, Tuon, Felipe Francisco, Tacconelli, Evelina, Carmeli, Yehuda, Bonomo, Robert A., Pascual, Álvaro, Paterson, David L., Rodríguez-Baño, Jesús, del Toro, M.D., Gálvez, J., Falcone, M., Russob, A., Karaiskos, I., Trecarichi, E.M., Losito, A.R., García-Vázquez, E., Gómez, J., Roilides, E., Iosifidis, E., Pournaras, S., Prim, N., Navarro, F., Mirelis, B., Origüen, J., Juan, R. San, Fernández-Ruiz, M., Almela, M., de la Calle, C., Martínez, J.A., Morata, L., Larrosa, N., Puig-Asensio, M., Bou, G., Molina, J., González, V., Bermejo, J., Rucci, V., de Gopegui, E. Ruiz, Marinescu, C.I., Fariñas, M.C., Cano, M.E., Gozalo, M., Paño-Pardo, J.R., Mora-Rillo, Marta, Gómez-Zorrilla, S., Tubau, F., Tsakris, A., Zarkotou, O., Antoniadou, A., Poulakou, G., Souli, M., Lowman, W., Virmani, D., Torre-Cisneros, Julian, Machuca, I., Gracia-Ahufinger, Irene, Azap, Ö.K., Helvaci, Ö., Sahin, A.O., Cantón, R., Pintado, V., Bartoletti, M., Giannella, M., Peter, S., Hamprecht, A., Badia, C., Xercavins, M., Fontanals, D., Jové, E.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01.11.2017
• Subjects: Adult; Aged; Aged, 80 and over; beta-Lactamase Inhibitors - therapeutic use; beta-Lactams - therapeutic use; Carbapenemase; Carbapenems; Drug Resistance, Multiple, Bacterial; Enterobacteriaceae - drug effects; Enterobacteriaceae - isolation & purification; Enterobacteriaceae Infections - drug therapy; Enterobacteriaceae Infections - microbiology; Escherichia coli; Extended-spectrum β-lactamase; Female; Global Health; Humans; Klebsiella pneumoniae; Male; Middle Aged; Retrospective Studies; Sepsis - drug therapy; Sepsis - microbiology; β-Lactam/β-lactamase inhibitor; β-Lactam/β-lactamase inhibitor; Carbapenemase; Carbapenems; Extended-spectrum β-lactamase; Escherichia coli; Klebsiella pneumoniae
• ISSN: 0924-8579; 1872-7913
• DOI: 10.1016/j.ijantimicag.2017.08.005

•Regional variation exists in therapy for bloodstream infections caused by ESBL-E or CPE.•Location influenced the empirical use of β-lactam/β-lactamase inhibitors (BLBLIs) or carbapenems.•BLBLI use for ESBL-E or combination therapy for CPE also varied by location.•Variation by location remained after adjustment for clinical factors.•These data may help clinical trial design and antimicrobial stewardship efforts. We describe regional differences in therapy for bloodstream infection (BSI) caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) or carbapenemase-producing Enterobacteriaceae (CPE). Patients (n = 1482) in 12 countries from an observational study of BSI caused by ESBL-E or CPE were included. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for the influence of country of recruitment on empirical use of β-lactam/β-lactamase inhibitors (BLBLIs) or carbapenems, targeted use of BLBLIs for ESBL-E and use of targeted combination therapy for CPE. Compared with Spain, BLBLI use for empirical therapy was least likely in sites from Israel (aOR 0.34, 95% CI 0.14–0.81), Greece (aOR 0.49, 95% CI 0.26–0.94) and Canada (aOR 0.31, 95% CI 0.11–0.88) but more likely in Italy (aOR 1.58, 95% CI 1.11–2.25) and Turkey (aOR 2.09, 95% CI 1.14–3.81). Empirical carbapenem use was more likely in sites from Taiwan (aOR 1.73, 95% CI 1.03–2.92) and USA (aOR 1.89, 95% CI 1.05–3.39) and less likely in Italy (aOR 0.44, 95% CI 0.28–0.69) and Canada (aOR 0.10, 95% CI 0.01–0.74). Targeted BLBLIs for ESBL-E was more likely in Italian sites. Treatment at sites within Israel, Taiwan, Turkey and Brazil was associated with less combination therapy for CPE. Although this study does not provide precise data on the relative prevalence of ESBL-E or CPE, significant variation in therapy exists across countries even after adjustment for patient factors. Better understanding of what influences therapeutic choices for these infections will aid antimicrobial stewardship efforts.