Seven-day antibiotic therapy for Enterobacterales bacteremia in high-risk neutropenic patients: toward a new paradigm.

PURPOSE: Data on short courses of antibiotic therapy for Enterobacterales bacteremia in high-risk neutropenic patients are limited. The aim of the study was to describe and compare the frequency of bacteremia relapse, 30-day overall and infection-related mortality, Clostridiodes difficile infection and length of hospital stay since bacteremia among those who received antibiotic therapy for 7 or 14 days. METHODS: This is a multicenter, prospective, observational cohort study in adult high-risk neutropenic patients with hematologic malignancies or hematopoietic stem cell transplant and monomicrobial Enterobacterales bacteremia. They received appropriate empirical antibiotic therapy, had a clinical response within 7 days, and infection source control. Clinical, epidemiological and outcomes variables were compared based on 7 or 14 days of AT. RESULTS: Two hundred patients were included (100, 7-day antibiotic therapy; 100, 14-day antibiotic therapy). Escherichia coli was the pathogen most frequently isolated (47.5%), followed by Klebsiella sp. (40.5%). Among those patients that received 7-day vs. 14-day antibiotic course, a clinical source of bacteremia was found in 54% vs. 57% (p = 0.66), multidrug-resistant Enterobacterales isolates in 28% vs. 30% (p = 0.75), and 40% vs. 47% (p = 0.31) received combined empirical antibiotic therapy. Overall mortality was 3% vs. 1% (p = 0.62), in no case related to infection; bacteremia relapse was 7% vs. 2% (p = 0.17), and length of hospital stay since bacteremia had a median of 9 days (IQR: 7-15) vs. 14 days (IQR: 13-22) (p = < 0.001). CONCLUSIONS: These data suggest that seven-day antibiotic therapy might be adequate for patients with high-risk neutropenia and Enterobacterales bacteremia, who receive appropriate empirical therapy, with clinical response and infection source control.

Ceftazidime-Avibactam Improves Outcomes in High-Risk Neutropenic Patients with Klebsiella pneumoniae Carbapenemase-Producing Enterobacterales Bacteremia.

Few studies have evaluated the efficacy of ceftazidime-avibactam (CA) for Klebsiella pneumoniae carbapenemase-producing Enterobacterales bacteremia (KPC-PEB) in high-risk neutropenic patients. This is a prospective multicenter observational study in high-risk neutropenic patients with multi-drug resistant Enterobacterales bacteremia. They were compared according to the resistance mechanism and definitive treatment provided: KPC-CPE treated with CA (G1), KPC-CPE treated with other antibiotics (G2), and patients with ESBL-producing Enterobacterales bacteremia who received appropriate definitive therapy (G3). Thirty-day mortality was evaluated using a logistic regression model, and survival was analyzed with Kaplan-Meier curves. A total of 238 patients were included: 18 (G1), 52 (G2), and 168 (G3). Klebsiella spp. (60.9%) and Escherichia coli (26.4%) were the Enterobacterales most frequently isolated, and 71% of the bacteremias had a clinical source. The resistance profile between G1 and G2 was colistin 35.3% vs. 36.5%, amikacin 16.7% vs. 40.4%, and tigeclycline 11.1% vs. 19.2%. The antibiotics prescribed in combination with G2 were carbapenems, colistin, amikacin, fosfomycin, tigecycline, and fluoroquinolones. Seven-day clinical response in G1 vs. G2 vs. G3 was 94.4% vs. 42.3% vs. 82.7%, respectively (p < 0.001). Thirty-day overall mortality in G1 vs. G2 vs. G3 was 22.2% vs. 53.8% vs. 11.9%, respectively (p < 0.001), and infection-related mortality was 5.5% vs. 51.9% vs. 7.7% (p < 0.001). The independent risk factors for mortality were Pitt score > 4: OR 3.63, 95% CI, 1.18-11.14 (p = 0.025) and KPC-PEB treated with other antibiotics: OR 8.85, 95% CI, 2.58-30.33 (p = 0.001), while 7-day clinical response was a protective factor for survival: OR 0.02, 95% CI, 0.01-0.08 (p < 0.001). High-risk neutropenic patients with KPC-CPE treated with CA had an outcome similar to those treated for ESBL-producing Enterobacterales, with higher 7-day clinical response and lower overall and infection-related mortality than those treated with other antibiotics. In view of these data, CA may be considered the preferred therapeutic option for KPC-PEB in high-risk neutropenic patients.

[Heart transplantation in an HIV-infected patient]. / Trasplante cardíaco en paciente infectado con el virus de la inmunodeficiencia humana.

Because of its own unfavourable evolution, HIV infection was until recently considered a contraindication for organ transplantation. The introduction of highly active antiretroviral therapy prolonged the life expectancy of these patients and allowed the manifestation of disorders directly or indirectly related to HIV infection, mainly liver, kidney and cardiovascular diseases. We present a case of cardiac transplantation due to dilated cardiomyopathy that was performed in a patient with a recently detected HIV infection. At 24 month follow-up, the patient is in very good health status, his CD4 are increasing and the viral load is undetectable. He did not present transplant rejection or any other complication. To our knowledge, there is no previous publication on heart transplantation in patients with HIV in South America. In view of the successful outcome of our case and of the few cases reported in the international literature, we consider that heart transplantation is a therapeutic option in correctly selected HIV patients.

Trasplante cardíaco en paciente infectado con el virus de la inmunodeficiencia humana / Heart transplantation in an HIV-infected patient

Hasta la consolidación del tratamiento antirretroviral combinado, la infección por HIV constituía, debido a su mal pronóstico, una contraindicación para el trasplante de órganos sólidos. El tratamiento antirretroviral combinado prolongó la expectativa de vida de estos pacientes, pero también permitió la manifestación a largo plazo de enfermedades directa o indirectamente ligadas al HIV, como hepatopatías, nefropatías y enfermedades cardiovasculares. Se presenta un caso de miocardiopatía dilatada tratada con trasplante cardíaco en un paciente con diagnóstico reciente de infección HIV. A los 24 meses, el paciente presentó CD4 en aumento y carga viral no detectable, sin complicaciones ni signos de rechazo. En nuestro conocimiento, no existen antecedentes de trasplante cardíaco en pacientes con HIV en Sudamérica. A la luz de la buena evolución de este caso y los pocos comunicados en la bibliografía internacional, consideramos que el trasplante cardíaco es una opción terapéutica en pacientes HIV positivos adecuadamente seleccionados.

Because of its own unfavourable evolution, HIV infection was until recently considered a contraindication for organ transplantation. The introduction of highly active antiretroviral therapy prolonged the life expectancy of these patients and allowed the manifestation of disorders directly or indirectly related to HIV infection, mainly liver, kidney and cardiovascular diseases. We present a case of cardiac transplantation due to dilated cardiomyopathy that was performed in a patient with a recently detected HIV infection. At 24 month follow-up, the patient is in very good health status, his CD4 are increasing and the viral load is undetectable. He did not present transplant rejection or any other complication. To our knowledge, there is no previous publication on heart transplantation in patients with HIV in South America. In view of the successful outcome of our case and of the few cases reported in the international literature, we consider that heart transplantation is a therapeutic option in correctly selected HIV patients.