Nosocomial extended-spectrum beta-lactamase-producing Klebsiella pneumoniae bacteremia in hemodialysis patients and the implications for antibiotic therapy

• Compare the efficacy of flomoxef with ertapenem in HD access related ESBL-Kp bacteremia.
• HD patients with critical illness are susceptible to ESBL-Kp bacteremia and have poor outcomes.
• Flomoxef use and Pitt bacteremia score are independently associated with mortality.
• Provide insight of using ertapenem other than flomoxef as an initial or de-escalating therapy.

SummaryBackgroundIn the face of increasing treatment options for extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) hemodialysis (HD) access-related bacteremia, the difference in clinical effectiveness between ertapenem and flomoxef remains unclear. We conducted this retrospective study to determine their efficacies and treatment outcomes.MethodsPatients on maintenance HD with fistula-, graft-, or catheter-related ESBL-Kp bacteremia were enrolled. Data related to clinical features and antibiotic treatments were collected. Outcome was determined by mortality resulting from bacteremia during the 14-day period after the collection of the first positive blood culture for flomoxef-susceptible ESBL-Kp.ResultsThe 64 patients studied had severe septicemia as determined by the Pitt bacteremia score; 50% (32/64) were in the intensive care unit (ICU) at the time of bacteremia. Old age (>65 years; 57.8%), malnutrition (albumin < 3.5 g/dl; 92.2%), a history of severe illnesses (defined by shock, intubation, or ICU stay; 82.5%), and prolonged hospitalization prior to the onset of bacteremia (>30 days; 75%) were also highly prevalent. The study population comprised nine fistula-, 10 graft-, and 45 HD catheter-related bacteremia cases, and the mortality rate was high (38/64, 59.4%). The mortality rate was significantly higher in the flomoxef treatment group than in the ertapenem treatment group (22/30, 73% vs. 16/34, 47%, p < 0.05). Among patients with catheter-related bacteremia, multivariate analyses revealed that flomoxef use (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.34–35.17) and Pitt bacteremia score (OR 4.37, 95% CI 1.28–5.26) were independently associated with mortality.ConclusionsIn accordance with our previous study, our results have demonstrated the inferiority of flomoxef to carbapenems in the treatment of HD access-related ESBL-Kp bacteremia and provide an insight into the possibility of using ertapenem rather than flomoxef as an initial or de-escalating therapy for infections caused by ESBL-producing bacteria.