1458 outpatient ertapenem therapy - confex
TRANSCRIPT
The prevalence of drug-resistant microorganisms is growing worldwide1,2. In our hospital, extended-spectrum-β-lactamase (ESBL)-producing Escherichia coli (E. coli) causes 70% of pyelonephritis.
Ertapenem is an exceptional antibiotic because of its once-daily dosing and broad spectrum of activity, suitable for outpatient parenteral antimicrobial therapy (OPAT)3. So far there are no reports on the efficacy of OPAT in Mexico. Our objective is to describe the outcomes, safety and cost of outpatient ertapenem therapy (OET) at our hospital.
Outpatient Ertapenem Therapy
Efficacy, Safety and Cost in a high prevalence ESBL-producing Enterobacteriaceae setting Arturo Ortiz-Álvarez, MD; Mónica A. Delgado-Ramírez, MD; Liudmilla Villegas-Acosta, MD; Montserrat Cuevas-Zúñiga, MD; Teresa Hernández-Carrera, NP; Rafael Valdez-Vázquez, MD; Ana Patricia Rodríguez-Zulueta, MD.
Hospital General Dr. Manuel Gea González , Mexico City, Mexico.
Study Design
We report a case series from the OPAT clinic at our Institution. The primary outcomes were cure, relapse and recurrence of infection. Side effects and complications of IV ertapenem therapy were also registered.
Patient Population
We included adult patients that received OET from January 28th 2014 to 28th December 2014 for a confirmed infections caused by ESBL-producing bacteria or as empiric treatment. Inpatients receiving ertapenem that were later discharged to the OPAT clinic were included.
In order to perform the cost analysis we randomly selected 20 patients with a diagnosis of pyelonephritis that received OET after hospital discharge (OET group) and compared them to patients who received entirely inpatient ertapenem therapy (IET); for this we allocated the first 20 cases of pyelonephritis in hospital discharges during 2013.
Definitions
Cure was defined as resolution of signs and symptoms of infection and improvement of laboratory and imaging studies at the end of OET. Episodes were classified as relapse if symptoms returned <30 days after termination of OET or recurrent if the interval was >30 days. Diagnosis, treatment duration, ertapenem side effects and venous line complications were established by the attending ID specialist.
In our hospital, OET is cost-effective and safe when compared to inpatient therapy.
Introduction
Patients and methods
Table 1. Baseline characteristics of the 99 patients
with OET n (% or SD)
Female 61 (62)
Mean age (years) 48±17
Diabetes mellitus
Arterial hypertension
Liver disease
Human immunodeficiency virus infection
Immunosuppressive therapy
Glomerular filtration rate <60ml/min
Obesity
Surgery in the preceding 3 months
Hospitalization in the 3 preceding months
39 (39)
19 (19)
5 (5)
2 (2)
3 (3)
3 (3)
17 (17)
25 (25)
45 (45)
Received 1 or 2 antibiotics in the preceding 3 months
Received >3 antibiotics in the preceding 3 months
41 (80)
10 (20)
Characteristics of the 88 patients
that required hospitalization
n (% or SD)
Received other IV antimicrobial prior to ertapenem 54 (61)
Days since admission to the beginning of ertapenem
Urinary tract infection (UTI) 1 a 3 days
Abdominal abscess > 4 days
4.4±6
44 (88)
14 (67)
Results
Conclusion Type of
infection
No. of
patients
No. of days
IET + OET
(mean±SD)
No. days
OET
(mean±SD)
Cure
(%)
No. patients
readmitted
after OET
No. patients
with relapse
or recurrence
No. patients
with
phlebitis
UTI 55 14 ± 9 7 ± 6 96 2 2 1
Abdominal
abscess 21 15 ± 10 8 ± 6 100 0 0 0
SSTI 9 13 ± 9 6 ± 5 89 0 1 0
JBI 7 42 ± 10 25 ± 6 100 1 0 1
GTI 4 13 ± 8 10 ± 6 100 0 0 0
Catheter-
related
bacteremia
3 14 ±8
10 ± 5
100 0 0 0
Total 99 15 ±9 9 (±6) 97 3 3 2
Table 4. Comparison of total cost of treatment in
patients with pyelonephritis in USD
Socio economic level OET IET*
1 $ 323 (n=7) $ 1, 221 (n=9)
2 $ 581 (n=13) $ 1, 539 (n=10)
Table 2. Microbiological data
Samples n Microorganism n (%)
Urine
culture *
49 ESBL-producing E. coli
None
29 (59)
20 (41)
Blood
culture ¬
55 ESBL-producing E. coli¶
ESBL-producing Salmonella
None
19 (34)
1 (2)
35 (64)
Abdominal-
abscess
18 ESBL-producing E. coli
C. freundii
None
14 (78)
1 (5)
3 (17)
Table 3. Clinical outcomes of patients with OET
Throughout the study period 137 patients initiated OPAT and 99 of them received OET. Baseline characteristics are described in Table 1 and microbiological data in Table 2.
*Patients with urinary tract infection (pyelonephritis, renal abscess and cystitis), ¬ Total population, ¶ 2 SSTI, 2 catheter-related bacteremias and 15 UTI
SSTI: skin and soft tissue infection, JBI: Joint and bone infection, GTI: genital tract infection, OET: Outpatient ertapenem therapy
Ertapenem therapy
Eighty eight patients required admission and received OET after discharge while 11 received ertapenem entirely as outpatients. Ninety-four percent of the patients received OET through a peripheral catheter. The duration of ertapenem therapy is described in Table 3.
We had one case of non-Clostridium difficile diarrhea, classified as adverse event. Intravascular line complications during OET included phlebitis in two patients.
Cost analysis The introduction of OPAT prevented 863 hospitalization days in the 99 patients with OET. The average cost of pyelonephritis treatment was significantly lower with OET ($928.00 USD cheaper per patient) compared to IET, as seen in Table 4. Costs per patient were significantly greater in patients receiving IET compared to OET.
1. Seaton RA, Barr DA. European Journal of Internal Medicine Outpatient parenteral antibiotic therapy : Principles and practice. Eur J Intern Med. 2013;24(7):617–623. doi:10.1016/j.ejim.2013.03.014.
2. Gales AC, Castanheira M, Jones RN, Sader HS. Antimicrobial resistance among Gram-negative bacilli isolated from Latin America: results from SENTRY Antimicrobial Surveillance Program (Latin America, 2008-2010). Diagn Microbiol Infect Dis 2012;73:354-60.
3. Chapman ALN, Dixon S, Andrews D, Lillie PJ, Bazaz R, Patchett JD. Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): A UK perspective. J Antimicrob Chemother. 2009;64(September):1316–1324. doi:10.1093/jac/dkp343.
References
Urinary tract infection
Abdominal abscess
Skin and soft tissue infection
Bone and joint infection
Genital tract infection
Catheter related bacteremia
Figure 1. Type of infection
Outcomes
Overall cure rate was 97% (see Table 3). We detected one relapse (renal abscess 12 days after the end of OET) and two cases of recurrent infection (one skin and soft tissue infection and one episode of pyelonephritis at days 35 and 34 respectively). Three patients were readmitted after OET (one episode of phlebitis, one recurrence and one relapse).
1458
OET: outpatient ertapanem therapy; IET: inpatient ertapenem therapy * One patient in the control group belonged to socioeconomic level 3
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