Increasing Resistance to Third-Generation Cephalosporins in Spontaneous Bacterial Peritonitis
2020; Elsevier BV; Volume: 95; Issue: 4 Linguagem: Inglês
10.1016/j.mayocp.2020.01.005
ISSN1942-5546
AutoresNishant Tripathi, Niki Koirala, Hirotaka Kato,
Tópico(s)Clostridium difficile and Clostridium perfringens research
ResumoWe read with immense interest the article entitled “Prevalence and Predictors of Third-Generation Cephalosporin Resistance in the Empirical Treatment of Spontaneous Bacterial Peritonitis” by Sunjaya et al.1Sunjaya D.B. Lennon R.J. Shah V.H. Kamath P.S. Simonetto D.A. Prevalence and predictors of third-generation cephalosporin resistance in the empirical treatment of spontaneous bacterial peritonitis.Mayo Clin Proc. 2019; 94: 1499-1508Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Notably, the rate of third-generation cephalosporin resistance in the authors’ study cohort was only 10% despite reported higher resistance rates in the recent literature from the United States, Europe, and China.2Lutz P. Nischalke H.D. Krämer B. et al.Antibiotic resistance in healthcare-related and nosocomial spontaneous bacterial peritonitis.Eur J Clin Invest. 2017; 47: 44-52Crossref PubMed Scopus (41) Google Scholar, 3Ardolino E. Wang S.S. Patwardhan V.R. Evidence of significant ceftriaxone and quinolone resistance in cirrhotics with spontaneous bacterial peritonitis.Dig Dis Sci. 2019; 64: 2359-2367Crossref PubMed Scopus (7) Google Scholar, 4Friedrich K. Nüssle S. Rehlen T. Stremmel W. Mischnik A. Eisenbach C. Microbiology and resistance in first episodes of spontaneous bacterial peritonitis: implications for management and prognosis.J Gastroenterol Hepatol. 2016; 31: 1191-1195Crossref PubMed Scopus (38) Google Scholar, 5Ning N.Z. Li T. Zhang J.L. et al.Clinical and bacteriological features and prognosis of ascitic fluid infection in Chinese patients with cirrhosis.BMC Infect Dis. 2018; 18: 253Crossref PubMed Scopus (9) Google Scholar A recent study we conducted at our university hospital revealed similarly higher third-generation cephalosporin resistance rate (36.1%). In our study, we defined culture-positive spontaneous bacterial peritonitis (SBP) as the presence of a polymorphonuclear neutrophil (PMN) count greater than 250 /μL in ascites, growth of one bacterial species within 5 days of ascitic fluid collection, and no identifiable source of intra-abdominal infection. Exclusion criteria comprised of age younger than 18 years, peritoneal dialysis, peritoneal carcinomatosis, and positive polymicrobial or fungal culture results. Sixty-one patients met the above criteria of 404 consecutive patients admitted with SBP (International Classification of Diseases, version 9 [ICD 9] code 567.23 and ICD 10 K65.2) between January 1, 2010, and December 31, 2018. Three of these cases were nosocomial-acquired, 39 were health care–associated, and 19 were community-acquired in our study, according to the modified criteria also applied by Sunjaya et al.1Sunjaya D.B. Lennon R.J. Shah V.H. Kamath P.S. Simonetto D.A. Prevalence and predictors of third-generation cephalosporin resistance in the empirical treatment of spontaneous bacterial peritonitis.Mayo Clin Proc. 2019; 94: 1499-1508Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Although the overall baseline patient characteristics and low culture-positive SBP rate (15.1%) were similar findings in both studies, the microbiology was vastly distinct. As Table 1 demonstrates, the most common microbiological etiology identified in our study was gram-negative rods (60.1%) compared with gram-positive organisms (55%) in their study. In our study, third-generation cephalosporin resistance was observed in 2 of 3 (66.7%) nosocomial-aquired, 15 of 39 (38.5%) heathcare-̅acquired, and 5 of 19 (26.3%) community- acquired cases; thus, overall 22 of 61 total cases (36.1%) demostrated resistance. Likewise, the in-hospital outcomes of our patients were poor: 20 (32.8%) died during the hospitalization, 16 (26.2%) were discharged to hospice, and only 25 (41.0%) were discharged with clinical improvement. A slight distinction in patient populations between the studies is worth noting; we excluded those with a PMN count less than 250/μL as they fail to meet SBP diagnostic criteria. However, 28% of the authors’ study population was comprised of these patients. Bacterascites have been associated with better outcomes than SBP.5Ning N.Z. Li T. Zhang J.L. et al.Clinical and bacteriological features and prognosis of ascitic fluid infection in Chinese patients with cirrhosis.BMC Infect Dis. 2018; 18: 253Crossref PubMed Scopus (9) Google Scholar However, this fact yet does not justify the low antibiotic resistance rate because no statistical significance in PMN count greater than 250/μL between ceftriaxone-resistant and susceptible groups was reported.1Sunjaya D.B. Lennon R.J. Shah V.H. Kamath P.S. Simonetto D.A. Prevalence and predictors of third-generation cephalosporin resistance in the empirical treatment of spontaneous bacterial peritonitis.Mayo Clin Proc. 2019; 94: 1499-1508Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Our data, gathered from a US academic institution, support the emerging concern of increasing antibiotic resistance among patients with SBP, comparable to other countries. Moreover, we developed univariate and multiple logistic regression models to predict the third-generation cephalosporin resistance, but were unable to identify independent predictors. As such, our study, along with many others, calls for larger well-designed studies to identify risk factors for third-generation cephalosporin resistance as they may provide conclusive data to alter our clinical practice on SBP empiric antimicrobial selection and enhance overall patient outcomes.TableFrequencies and Susceptibilities of Pathogens in Spontaneous Bacterial PeritonitisaNA = Not availablePathogenFrequencybAll frequency and total percentages are out of total 61 cases. All other percentages represent percent susceptibility to each drug of each organism or group of organisms.CeftriaxoneCefepimeQuinolonesVancomycinGram-negative rods37 (60.1)24 (64.9)cBold-faced values represent overall susceptibilities of gram-negative rods, gram-positive cocci and gram-positive rods to ceftriaxone.30 (81.1)26 (70.3)NA E coli21 (34.4)16 (76.2)17 (81.0)12 (57.1)NA K pneumoniae6 (9.8)5 (83.3)5 (83.3)6 (100.0)NA P aeruginosa3 (4.9)0 (0.0)1 (33.3)1 (33.3)NA S marcescens3 (4.9)1 (33.3)3 (100.0)3 (100.0)NA Enterobacter cloacae1 (1.6)1 (100.0)1 (100.0)1 (100.0)NA Citrobacter braakii2 (3.3)0 (0.0)2 (100.0)2 (100.0)NA Citrobacter freundii1 (1.6)1 (100.0)1 (100.0)1 (100.0)NAGram-positive cocci20 (32.8)10 (50.0)cBold-faced values represent overall susceptibilities of gram-negative rods, gram-positive cocci and gram-positive rods to ceftriaxone.10 (50.0)4 (20.0)17 (85.0) Staphylococcus spp.6 (9.8)0 (0.0)0 (0.0)0 (0.0)4 (66.7)MRSA3 (4.9)0 (0.0)0 (0.0)0 (0.0)3 (100.0)S epidermidisdSusceptibility for 1 of 2 Staphylococcus epidermidis samples was not reported.2 (3.3)0 (0.0)0 (0.0)0 (0.0)1(100.0)Coag-neg stapheSusceptibilities for coagulase-negative Staphylococcus and Paenibacillus barengoltzii were not reported.1 (1.6)NANANANA Streptococcus spp.10 (16.4)10 (100.0)10 (100.0)4 (40.0)10 (100.0)S pneumoniae3 (4.9)3 (100.0)3 (100.0)3 (100.0)3 (100.0)S anginosus2 (3.3)2 (100.0)2 (100.0)NA2 (100.0)S mitis/oral is2 (3.3)2 (100.0)2 (100.0)NA2 (100.0)S parasanguinis1 (1.6)1 (100.0)1 (100.0)NA1 (100.0)S salivarius1 (1.6)1 (100.0)1 (100.0)NA1 (100.0)Beta hemolytic strep1 (1.6)1 (100.0)1 (100.0)1 (100.0)1 (100.0) Enterococcus spp.4 (6.6)0 (0.0)0 (0.0)NA3 (75.0)E faecium2 (3.3)0 (0.0)0 (0.0)NA1 (50.0)E faecalis1 (1.6)0 (0.0)0 (0.0)NA1 (100.0)E pallens1 (1.6)0 (0.0)0 (0.0)NA1 (100.0)Gram-positive rods4 (6.6)2 (50.0)cBold-faced values represent overall susceptibilities of gram-negative rods, gram-positive cocci and gram-positive rods to ceftriaxone.NANA0 (0.0) Listeria monocytogenes1 (1.6)0 (0.0)NANANA Eggerthella Lenta1 (1.6)1 (100.0)NANANA Lactobacillus1 (1.6)1 (100.0)NANA0 (0.0) Paenibacillus barengoltziieSusceptibilities for coagulase-negative Staphylococcus and Paenibacillus barengoltzii were not reported.1 (1.6)NANANANATotalbAll frequency and total percentages are out of total 61 cases. All other percentages represent percent susceptibility to each drug of each organism or group of organisms.6136 (59.0)40 (65.6)30 (49.2)17 (27.9)Values are presented as n (%).a NA = Not availableb All frequency and total percentages are out of total 61 cases. All other percentages represent percent susceptibility to each drug of each organism or group of organisms.c Bold-faced values represent overall susceptibilities of gram-negative rods, gram-positive cocci and gram-positive rods to ceftriaxone.d Susceptibility for 1 of 2 Staphylococcus epidermidis samples was not reported.e Susceptibilities for coagulase-negative Staphylococcus and Paenibacillus barengoltzii were not reported. Open table in a new tab Values are presented as n (%). The authors thank Kishore Karri, MD, Tushi Singh, MD, and Olalekan Akanbi, MD, from the Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, for their involvement in study design and data collection. In reply — Increasing Resistance to Third-Generation Cephalosporins in Spontaneous Bacterial PeritonitisMayo Clinic ProceedingsVol. 95Issue 4PreviewWe appreciate the comments submitted by Dr Tripathi and colleagues on our recent manuscript on prevalence and predictors of cephalosporin resistance in spontaneous bacterial peritonitis (SBP). Dr Tripathi and colleagues elegantly report the prevalence of cephalosporin resistance in spontaneous bacterial peritonitis at another US academic institution, which is significantly higher than observed in our series1 (36% compared with 10%). Variation in regional practice, local microbiota, and antibiotic stewardship may at least partly account for the differences observed in resistance patterns. Full-Text PDF Prevalence and Predictors of Third-Generation Cephalosporin Resistance in the Empirical Treatment of Spontaneous Bacterial PeritonitisMayo Clinic ProceedingsVol. 94Issue 8PreviewTo better characterize the changing patterns of spontaneous bacterial peritonitis (SBP) in a tertiary academic center in the United States by identifying the prevalence of gram-positive organisms and cephalosporin resistance along with predictors of mortality and antibiotic drug resistance. Full-Text PDF
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