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ESBL: M100-S17 states that all pens, cephs, and aztreo should be reported as resistant for confirmed ESBL positive enterics. What's not clearly stated is how to report pen/inhibitor combination drugs for ESBL positive orgs. Looking for some guidance. Thank you. Richard Dern, St Marys Hosp, Madison WI
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M100-S17 does not specifically indicate any reporting restrictions for the penicillin-inhibitor combinations for ESBLs, because there is no compelling reason to suppress these results. However, the antibiotic of choice for infections believed to be caused by these types of organisms are the carbapenems. Penicillin-inhibitor combinations, such as piperacillin-tazobactam, can be ineffective in the treatment of ESBL positive Gram-negative rods, but in some cases they are effective, especially for urinary tract infections. It is prudent to confirm the susceptibility of these agents by another method (e.g. confirm with a disk test if the usual method of testing in your lab is an automated instrument). There have been reports of method failures to detect penicillin-inhibitor combination resistance for automated systems. However, once confirmed, if these agents are susceptible, they should be reported as such.
Exceptions to reporting these agents include the opinion of Infectious Disease physicians or special circumstances during an outbreak. Burgess et al (1) in a large study of bacteremia showed that the success rate of carbepenems was twice that of either cefepime or piperacillin/tazobactam therapy. Thus, for bacteremia, it may be desirable to suppress the result (1,2,3, 4) or to indicate in a notation that “carbapenems are the first line drugs of choice for bacteremia with ESBLs.”
1. Burgess DS, Hall RG 2nd, Lewis JS 2nd, Jorgensen JH, Patterson JE. Clinical and microbiologic analysis of a hospital's extended-spectrum beta-lactamase-producing isolates over a 2-year period. Pharmacotherapy. 2003 Oct;23(10):1232-7
2. Paterson DL.Recommendation for treatment of severe infections caused by Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs). Clin Microbiol Infect. 2000 Sep;6(9):460-3.
3. Reese AM, Frei CR, Burgess DS.Pharmacodynamics of intermittent and continuous infusion piperacillin/tazobactam and cefepime against extended-spectrum beta-lactamase-producing organisms. Int J Antimicrob Agents. 2005 Aug;26(2):114-9
4. Zimhony O, Chmelnitsky I, Bardenstein R, Goland S, Hammer Muntz O, Navon Venezia S, Carmeli Y. Endocarditis caused by extended-spectrum-beta-lactamase-producing Klebsiella pneumoniae: emergence of resistance to ciprofloxacin and piperacillin-tazobactam during treatment despite initial susceptibility. Antimicrob Agents Chemother. 2006 Sep;50(9):3179-82
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