Oral beta-lactam step down in bacteremic E. coli urinary tract infections

Stephan Saad, Neil Mina, Colin Lee, Kevin Afra, Stephan Saad, Neil Mina, Colin Lee, Kevin Afra

Abstract

Background: Literature is scarce regarding oral step down to beta-lactams in bacteremic urinary tract infections. Oral fluoroquinolones are an accepted and common step down for bacteremic urinary tract infections; however, their use is associated with mounting safety concerns. We compared clinical cure in patients with E. coli bacteremic urinary tract infections who were stepped down to oral beta-lactams compared to oral fluoroquinolones.

Methods: This multicentre retrospective cohort study included patients with first positive concurrent urine and blood cultures from January 2016 to December 2016. Patients were included if they received empiric intravenous beta-lactam therapy with step down to either oral beta-lactam or fluoroquinolone for treatment completion. The primary outcome was clinical cure. Secondary outcomes were length of hospitalization, all-cause mortality and C. difficile infection. Multivariate analysis and propensity score were used to control for confounding.

Results: A total of 207 patients were identified with bacteremic E.coli urinary tract infections. Clinical cure was achieved in 72/77 (94%) in the oral beta-lactam group versus 127/130 (98%) in the oral fluoroquinolone group (absolute difference - 4.2, 95% confidence interval [CI] -10.3 to 1.9%, p = 0.13). The adjusted odds ratio (OR) for clinical cure with oral beta-lactams was 0.31 (95% CI 0.05-1.90, p = 0.21); propensity score adjusted analysis showed a similar result. There was no statistically significant difference in secondary outcomes.

Conclusions: Oral beta-lactams appear to be a safe and effective step down option in bacteremic E. coli urinary tract infections compared to oral fluoroquinolones.

Keywords: Antibiotics; E. coli; Gram negative bacteremia; Oral step down; Urinary tract infection.

Conflict of interest statement

No competing interests to declare.

References

    1. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007;45:273–280. doi: 10.1086/519268.
    1. Zhanel GG, Hisanaga TL, Laing NM, et al. Antibiotic resistance in outpatient urinary isolates: final results from the north American urinary tract infection collaborative Alliance (NAUTICA) Int J Antimicrob Agents. 2005;26:380–388. doi: 10.1016/j.ijantimicag.2005.08.003.
    1. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52:e103–e120. doi: 10.1093/cid/ciq257.
    1. U.S. Food & Drug Administration . FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. 2016.
    1. U.S. Food & Drug Administration . FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. 2016.
    1. U.S. Food & Drug Administration . FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. 2018.
    1. U.S. Food & Drug Administration . FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. 2018.
    1. Health Canada . Summary safety review - Oral FLUOROQUINOLONES - assessing the potential risk of retinal detachment. 2016.
    1. Health Canada . Summary safety review - Fluoroquinolones - assessing the potential risk of persistent and disabling side effects. 2017.
    1. European Medicines Agency . Quinolone- and fluoroquinolone-containing medicinal products. 2019.
    1. Robinson JL, Finlay JC, Lang ME, Bortolussi R. Canadian Paediatric society, infectious diseases and immunization committee, community Paediatrics committee. Urinary tract infections in infants and children: diagnosis and management. Paediatr Child Health. 2014;19:315–325. doi: 10.1093/pch/19.6.315.
    1. Angel JL, O’Brien WF, Finan MA, Morales WJ, Lake M, Knuppel RA. Acute pyelonephritis in pregnancy: a prospective study of oral versus intravenous antibiotic therapy. Obstet Gynecol. 1990;76:28–32.
    1. Millar LK, Wing DA, Paul RH, Grimes DA. Outpatient treatment of pyelonephritis in pregnancy: a randomized controlled trial. Obstet Gynecol. 1995;86:560–564. doi: 10.1016/S0029-7844(95)80016-6.
    1. Wing DA, Hendershott CM, Debuque L, Millar LK. A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy. Obstet Gynecol. 1998;92:249–253.
    1. Wing DA, Hendershott CM, Debuque L, Millar LK. Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks. Obstet Gynecol. 1999;94:683–688.
    1. Sanchez M, Collvinent B, Miró O, et al. Short-term effectiveness of ceftriaxone single dose in the initial treatment of acute uncomplicated pyelonephritis in women. A randomised controlled trial. Emerg Med J. 2002;19:19–22. doi: 10.1136/emj.19.1.19.
    1. Monmaturapoj T, Montakantikul P, Mootsikapun P, Tragulpiankit P. A prospective, randomized, double dummy, placebo-controlled trial of oral cefditoren pivoxil 400mg once daily as switch therapy after intravenous ceftriaxone in the treatment of acute pyelonephritis. Int J Infect Dis. 2012;16:e843–e849. doi: 10.1016/j.ijid.2012.07.009.
    1. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for Sepsis and septic shock (Sepsis-3) JAMA. 2016;315:801–810. doi: 10.1001/jama.2016.0287.
    1. Tamma PD, Conley AT, Cosgrove SE, et al. Association of 30-day mortality with Oral step-down vs continued intravenous therapy in patients hospitalized with Enterobacteriaceae bacteremia. JAMA Intern Med. 2019;179(3):316–323. doi: 10.1001/jamainternmed.2018.6226.
    1. Mercuro NJ, Stogsdill P, Wungwattana M. Retrospective analysis comparing oral stepdown therapy for enterobacteriaceae bloodstream infections: fluoroquinolones versus β-lactams. Int J Antimicrob Agents. 2018;51:687–692. doi: 10.1016/j.ijantimicag.2017.12.007.
    1. Punjabi C, Tien V, Meng L, Deresinski S, Holubar M. Oral Fluoroquinolone or Trimethoprim-sulfamethoxazole vs. ß-lactams as Step-Down Therapy for Enterobacteriaceae Bacteremia: Systematic Review and Meta-analysis. Open Forum Infect Dis. 2019;6:ofz364. doi: 10.1093/ofid/ofz364.
    1. Deshpande A, Pasupuleti V, Thota P, et al. Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother. 2013;68:1951–1961. doi: 10.1093/jac/dkt129.
    1. Dingle KE, Didelot X, Quan TP, et al. Effects of control interventions on Clostridium difficile infection in England: an observational study. Lancet Infect Dis. 2017;17:411–421. doi: 10.1016/S1473-3099(16)30514-X.
    1. Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med. 2019;380:415–424. doi: 10.1056/NEJMoa1808312.
    1. Li H-K, Rombach I, Zambellas R, et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380:425–436. doi: 10.1056/NEJMoa1710926.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj