Cefepime vs carbapenems for treating third-generation cephalosporin-resistant AmpC & beta;-lactamase-hyperproducing Enterobacterales bloodstream infections: a multicenter retrospective study

Objectives: AmpC & beta;-lactamase-hyperproducing Enterobacterales (ABLHE) bloodstream infections (BSI) are emerging and leading to therapeutic challenges worldwide. Prescriptions of carbapenems may lead to the emergence of resistance. This study aimed to compare cefepime with carbapenems for the treatment of third-generation cephalosporin-resistant ABLHE BSI.Methods: This retrospective multicenter study included patients with ABLHE BSI from two tertiary hospitals in France, between July 2017 and July 2022. Non-AmpC-producing Enterobacterales, extendedspectrum & beta;-lactamase, and carbapenemase-producing Enterobacterales were excluded. Cefepime was prescribed only in case of minimal inhibitory concentration <1 mg/l. The primary outcome was 30-day inhospital mortality from the date of index blood culture. Secondary outcomes were infection recurrence and treatment toxicity. An inverse probability of treatment weighting approach was used to balance the baseline characteristics between the two groups.Results: We analyzed 164 BSI, which included 77 in the cefepime group and 87 in the carbapenem group. In the weighted cohort, the 30-day mortality rates were similar between the cefepime group (23.3%) and the carbapenem group (19.6%) with a relative risk of 1.19 (95% confidence interval, 0.61-2.33 P = 0.614). No significant difference in recurrence or toxicity was found between the two groups.Conclusion: This study adds evidence in favor of the use of cefepime for treating third-generation cephalosporin-resistant ABLHE BSI in case of minimal inhibitory concentration < 1 mg/l, which could spare carbapenems.& COPY; 2023 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Automated summary

This study compared the use of cefepime with carbapenems for the treatment of third-generation cephalosporin-resistant ABLHE bloodstream infections. The results showed no significant difference in 30-day in-hospital mortality, infection recurrence, or treatment toxicity between the two groups. Therefore, this study supports the use of cefepime in cases with a minimal inhibitory concentration < 1 mg/l to spare carbapenems.