Clinical outcomes following treatment of Enterobacter species pneumonia with piperacillin/tazobactam compared to cefepime or ertapenem.

BACKGROUND: Enterobacter spp. are a common cause of nosocomial pneumonia and treatment can be complicated by AmpC resistance. Carbapenems are the treatment of choice; however, alternatives are needed. Cefepime has been shown to be non-inferior to carbapenems. There are limited data to support the use of piperacillin/tazobactam. The objective of this study was to determine if piperacillin/tazobactam is non-inferior to cefepime or ertapenem for Enterobacter pneumonia treatment. OBJECTIVES: To compare the rate of clinical cure in patients with Enterobacter pneumonia receiving definitive treatment with piperacillin/tazobactam, cefepime, or ertapenem. Secondary outcomes included hospital mortality, infection-related length of stay, duration of mechanical ventilation, recurrent pneumonia, and resistance. METHODS: Retrospective, single-center study. RESULTS: Of 114 patients included, 59 received definitive treatment with piperacillin/tazobactam and 55 received cefepime or ertapenem. There was no difference in the proportion of patients who achieved clinical cure in the piperacillin/tazobactam group compared to the cefepime or ertapenem group (76.3% vs. 87.3%, P = 0.13). Treatment group was not associated with clinical cure when controlling for confounders in multivariable logistic regression (adjusted odds ratio [OR] 0.59, 95% confidence interval [CI] 0.15-2.37). The rate of recurrent pneumonia was 11.4% in the piperacillin/tazobactam group and 6.7% in the cefepime or ertapenem group (P = 0.48). Other secondary outcomes did not differ between the groups. CONCLUSIONS: In this retrospective study of patients with Enterobacter pneumonia, clinical cure with piperacillin/tazobactam was comparable to that with cefepime or ertapenem; however, a prospective trial with a larger population is needed to determine if definitive treatment with piperacillin/tazobactam is non-inferior to definitive treatment with cefepime or ertapenem.

Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax.

Objective: To describe the efficacy, safety, dosing regimen, and administration technique of intrapleural alteplase for the treatment of retained hemothorax. Data Sources: A PubMed, EMBASE, and Google Scholar search (January 2000 to February 2019) was conducted with the search terms intrapleural, fibrinolytic, fibrinolysis, alteplase, tissue plasminogen activator, and hemothorax. Study Selection and Data Extraction: Articles were included if they described the use of intrapleural alteplase in adult patients with a retained hemothorax; single patient case reports and abstracts were excluded. Data Synthesis: A total of 6 retrospective reviews and 1 meta-analysis were identified for inclusion. A variety of dosing strategies have been defined for the administration of intrapleural alteplase ranging from 6 to 100 mg, volume of fluid from 50 to 120 mL of normal saline, and the number of total doses has ranged from 1 to 8 over the treatment course. A majority of studies showed a greater than 80% success rate and less than 7% bleeding rate. Relevance to Patient Care and Clinical Practice: Because of the paucity of data for use of alteplase in retained hemothorax and administration of a high-risk medication, this review provides dosing and administration recommendations based on reported safety and efficacy. Conclusion: Administration of intrapleural alteplase should be considered in patients with retained hemothorax as an alternative to surgical intervention. In contrast to intrapleural alteplase administration for other indications such as empyema, higher doses and volumes of alteplase are recommended for retained hemothorax.

Increased Risk of Acute Kidney Injury in Critically Ill Children Treated With Vancomycin and Piperacillin/Tazobactam.

OBJECTIVES: Compare the rates of acute kidney injury in critically ill children treated with vancomycin and piperacillin-tazobactam versus vancomycin and ceftriaxone. DESIGN: Retrospective cohort study. SETTING: A large tertiary care children's hospital in an urban setting. PATIENTS: Children greater than or equal to 2 months old admitted to the PICU who received greater than or equal to 48 consecutive hours of vancomycin and piperacillin-tazobactam or vancomycin and ceftriaxone. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Acute kidney injury was defined as a minimum 50% increase in serum creatinine, adjusted for total fluid balance, from baseline over a 48-hour period. Bivariate analysis compared treatment groups and acute kidney injury groups. A multivariable logistic regression model was fit for acute kidney injury including covariable analysis. The study included 93 children. There were no differences between treatment groups in terms of age, severity of illness, baseline renal function, vancomycin dosing, or vancomycin trough concentrations. Children who received vancomycin and piperacillin-tazobactam had a higher cumulative frequency of acute kidney injury than those who received vancomycin and ceftriaxone 915/58 [25.9%] vs 3/35 [8.6%]; p = 0.041). After controlling for vancomycin trough concentration, age, concurrent nephrotoxin exposure, and use of vasopressors, exposure to piperacillin-tazobactam significantly increased the risk of acute kidney injury (adjusted odds ratio, 4.55; 95% CI [1.11-18.7]; p = 0.035) compared with ceftriaxone. Use of vasopressors (adjusted odds ratio, 3.73 [95% CI, 1.14-12.3]) and a vancomycin trough greater than or equal to 15 mg/dL (adjusted odds ratio, 4.12 [95% CI, 1.12-15.2)] was also associated with acute kidney injury. Length of stay was longer in children with acute kidney injury (median, 18.0 days; interquartile range, 7.76-29.7) compared with those without acute kidney injury (median, 6.21 days; interquartile range, 2.92-15.6; p = 0.017). CONCLUSIONS: In critically ill children, acute kidney injury occurred more in patients treated with vancomycin and piperacillin-tazobactam versus vancomycin plus ceftriaxone. After controlling for covariates, exposure to piperacillin-tazobactam was associated with an increased odds of acute kidney injury development.