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Abstract：
Carbapenems are frequently used to treat infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E), but carbapenem-resistant Enterobacteriaceae bacteria are a clinical concern. Although cephamycins (cefmetazole; CMZ) have been shown to be effective against mild cases of ESBL-E infection, data on their use for severe ESBL-E infections with sepsis or septic shock remain scarce. Herein, we discuss a de-escalation therapy to CMZ that could be used after empiric antibiotic therapy in ICU patients with sepsis or septic shock caused by ESBL-E bacteremia. A sequence of 25 cases diagnosed with sepsis or septic shock caused by ESBL-E bacteria was evaluated. The attending infectious disease specialist physicians selected the antibiotics and decided the de-escalation timing. The median SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) severity scores were 8 and 30; the rate of septic shock was 60%. Infections originated most frequently with urinary tract infection (UTI) (56%) and Escherichia coli (85%). Eleven patients were de-escalated to CMZ after vital signs were stable, and all survived. No patients died of UTI regardless of with or without de-escalation. The median timing of de-escalation antibiotic therapy after admission was 4 days (range, 3-6 days). At the time of de-escalation, the median SOFA score fell from 8 to 5, the median APACHE II score from 28 to 22, and the rate of septic shock from 55% to 0%. We conclude that for sepsis in UTI caused by ESBL-E bacteremia, de-escalation therapy from broad-spectrum antibiotics to CMZ is a potential treatment option when vital signs are stable.
摘要：
碳青霉烯类经常用于治疗由产超广谱β-内酰胺酶肠杆菌（ESBL-E）引起的感染，但是耐碳青霉烯类肠杆菌科细菌是临床关注的问题。尽管头孢霉素（头孢美唑；CMZ）已被证明对ESBL-E感染的轻度病例有效，关于其用于严重ESBL-E感染伴脓毒症或脓毒性休克的数据仍然很少.在这里，我们讨论了对于由ESBL-E菌血症引起的脓毒症或脓毒性休克的ICU患者,在经验性抗生素治疗后可使用CMZ的降阶梯治疗.评估了25例诊断为由ESBL-E细菌引起的脓毒症或脓毒性休克的患者的序列。主治传染病专科医生选择了抗生素并决定了降级时间。中位SOFA（序贯器官衰竭评估）和APACHEII（急性生理学和慢性健康评估II）严重程度评分分别为8和30；感染性休克的发生率为60％。感染最常见的是尿路感染（UTI）（56％）和大肠杆菌（85％）。11例患者在生命体征稳定后降低至CMZ，所有人都活了下来。无论是否有降级，都没有患者死于UTI。入院后抗生素降阶梯治疗的中位时间为4天（范围，3-6天）。在降级的时候，SOFA评分中位数从8分下降至5分,APACHEII评分中位数从28分下降至22分,感染性休克发生率从55%下降至0%.我们得出的结论是，对于由ESBL-E菌血症引起的UTI中的败血症，当生命体征稳定时,从广谱抗生素到CMZ的降阶梯治疗是一种潜在的治疗选择.
