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This Journal section presents a real, challenging case involving a multidrug-resistant organism. The case authors present the rationale for
their therapeutic strategy and discuss the impact of mechanisms of resistance on clinical outcome. An expert clinician then provides a commentary on the case.
New antibiotic options are urgently needed for the treatment of carbapenem-resistant Enterobacteriaceae infections. We report a
64-year-old female with prolonged hospitalization following an intestinal transplant who developed refractory bacteremia due
to a serine carbapenemase-producing pandrug-resistant isolate of Klebsiella pneumoniae. After failing multiple antimicrobial
regimens, the patient was successfully treated.
CASE PRESENTATION
mase [NDM], and Verona integron-encoded metallo--lactamase [VIM]) and class D (oxacillinase [OXA]-type) carbapenemase genes were not detected. The isolate was resistant to
aminoglycosides but susceptible to tigecycline (MIC, 0.38 g/ml)
and colistin (MIC, 0.19 g/ml). The patient was started on a combination of tigecycline (1 dose of 100 mg i.v., followed by 50 mg
i.v. q12h) and colistin (2.5 mg i.v. q12h) and completed a 14-day
course for complicated intra-abdominal infection (cIAI) due to
carbapenem-resistant Klebsiella pneumoniae (CRKP). The patients subsequent hospital course was complicated by renal failure, requiring hemodialysis and chronic ventilator-dependent respiratory failure. On postoperative day 36, the patient developed
fever and hypotension and was noted to have copious respiratory
secretions. Bronchoalveolar lavage fluid grew CRKP at 104
CFU/ml; the isolate was now resistant to tigecycline (MIC, 256
g/ml) but susceptible to colistin (MIC, 1 g/ml). The patient was
started on a combination of colistin (2.5 mg i.v. q24h) and extended-infusion meropenem (500 mg i.v. q24h), with the dose based
on renal clearance, for ventilator-associated pneumonia due to
CRKP with a good clinical response.
On postoperative day 65, the patient developed recurrent fever
and leukocytosis and was found to have CRKP bacteremia. Since
the bloodstream infection (BSI) was suspected to be catheter re-
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Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USAa; Miami Transplant Institute and Department
of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USAb; Department of Pharmacy, Jackson Memorial Hospital, Miami, Florida, USAc; Department of
Microbiology, Jackson Memorial Hospital, Miami, Florida, USAd; Department of Microbiology, University of Miami, Miami, Florida, USAe; Servicio de Microbiologa, Hospital
Universitario Ramn y Cajal and Instituto Ramn y Cajal de Investigacin Sanitaria (IRYCIS), Madrid, Spainf; Red Espaola de Investigacin en Patologa Infecciosa (REIPI),
Madrid, Spaing
Mortality rates for cases of CRKP bacteremia exceed 50% (1, 2).
Combination antimicrobial therapy yields the best outcomes (3),
but treatment options are limited. The two main antibiotic options available for CRKP infection are colistin and tigecycline,
both of which have suboptimal efficacy and toxicity profiles.
Colistin remains the most active agent against CRKP, but its tolerability is limited due to common and serious nephrotoxicity and
neurotoxicity. Tigecycline is usually not recommended for the
treatment of BSI in critically ill patients because it does not achieve
adequate serum levels (4) and higher mortality rates associated
with the use of tigecycline have been reported (5). In addition, the
emergence of CRKP strains resistant to colistin and tigecycline is
increasingly reported (1). Intravenous fosfomycin has been used
in Europe for the treatment of CRKP infections with promising
results and a low incidence of adverse events (2, 6). Unfortunately,
intravenous fosfomycin is not currently available in the United
States. In addition, the relatively quick emergence of resistance
during therapy, particularly among immunocompromised hosts,
is a major limitation of fosfomycin (6).
Ceftazidime-avibactam (CAZ-AVI; AstraZeneca/Forest Laboratories) was until recently an investigational antimicrobial but
has now been approved by the U.S. Food and Drug Administration
(FDA) for the treatment of adult patients with cIAI (in combination
with metronidazole) and complicated urinary tract infections (cUTI)
(http://www.fda.gov/newsevents/newsroom/pressannouncements
/ucm435629.htm). CAZ-AVI consists of a combination of ceftazidime and the novel non--lactam -lactamase inhibitor avibactam. The addition of avibactam greatly improves the activity
of ceftazidime against most species of Enterobacteriaceae (4- to
1,024-fold reduction in MIC) (7), including ceftazidime-nonsusceptible pathogens. CAZ-AVI demonstrates in vitro activity
against extended-spectrum -lactamase (ESBL) and KPC but not
metallo--lactamase (e.g., VIM, NDM, IMP) producers. In an in
vitro study of 1,466 Gram-negative bacterial isolates collected
from hospitalized patients in the United States during 2012, a total
of 99.8% of Enterobacteriaceae isolates from patients with BSI,
99.4% from pneumonia patients, and 100% from patients with
IAI and UTI exhibited a CAZ-AVI MIC of 4 g/ml, which is the
Clinical and Laboratory Standards Institute (CLSI) susceptible
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breakpoint for ceftazidime when tested alone against Enterobacteriaceae (8). In phase 2 clinical trials, CAZ-AVI has been proved to
be safe and effective in the treatment of cUTI as well cIAI (in
combination with metronidazole) (9, 10). Phase 3 clinical trials of
CAZ-AVI in patients with cUTI (NCT01595438) and cIAI
(NCT01499290, NCT01726023, and NCT01500239) were recently
completed, and phase 3 studies in patients with nosocomial pneumonia (NCT01808092) are ongoing (https://clinicaltrials.gov). The efficacy of CAZ-AVI in the treatment of BSI has not been established.
The addition of fosfomycin was considered for our patient, but
her isolate was resistant (MIC, 64 g/ml). Based on previous reports suggesting the efficacy of double-carbapenem regimens for
carbapenemase-producing multidrug-resistant Klebsiella pneumoniae (11, 12), the patient was switched to a combination of
colistin (1.25 mg/kg i.v. q12h), meropenem (1 g i.v. q12h), and
ertapenem (1 g i.v. q24h), adjusted to renal function. She initially
responded to this regimen but developed breakthrough bacteremia 12 days later. The isolate had now become resistant to colistin
(MIC, 12 g/ml). At this point, an emergency investigational new
drug application (EIND no. 125649) was obtained from the FDA
to administer CAZ-AVI to our patient with refractory CRKP bacteremia. The medication was kindly provided by AstraZeneca/
Forest Laboratories after a compassionate use request. This singlepatient protocol was also approved by our local institutional
review board, and the patient provided written informed consent.
COMMENTARY
tion with metronidazole, and complicated urinary tract infections, including pyelonephritis, who have limited or no treatment
options (7). Avibactam is a synthetic non--lactam -lactamase
inhibitor that inhibits the activities of Ambler class A and C -lactamases and some Ambler class D enzymes, including KPC carbapenemases, AmpC, and OXA-48-like carbapenemases, respectively. However, it does not inhibit metallo--lactamases, such us
VIM or NDM variants.
In the case presentation above, Camargo et al. have described
the treatment of a patient with a bacteremia due to a KPC-producing K. pneumoniae isolate that was susceptible only to colistin
and tigecycline. Different antibiotic combination regimens were
subsequently administered, including double or triple therapy
with tigecycline (1 dose of 100 mg i.v. followed by 50 mg i.v. q12h),
colistin (2.5 mg i.v. q24h), and extended-infusion of meropenem
(0.5 to 1 g i.v. q24h), all adjusted for impaired renal function. Due
to refractory bacteremia and previous reports suggesting efficacy
of a double-carbapenem regimen for carbapenemase-producing
K. pneumoniae infections, the patient was treated with colistin
(1.25 mg i.v. q24h), meropenem (1 g i.v. q24h), and ertapenem (1
g i.v. q24h). The emergence of colistin resistance, a situation not
infrequently observed in KPC-producing K. pneumoniae isolates,
was noted, and the patient was switched to a combination of CAZAVI (1 g/250 mg i.v. q8h) and ertapenem (1 g i.v. q24). The use of
CAZ-AVI in a patient with bacteremia, an indication that is not
included in the FDA prescribing information for this product, has
not been previously reported, unlike the association of different
carbapenems (Table 2).
Double-carbapenem therapy was initially explored in animal
models and later used in patients infected with CPE (Table 2).
Although the rationale for this combination has not been extensively explored, it is hypothesized that one of the carbapenem
compounds distracts the carbapenemase enzyme acting as a suicide inhibitor, thus allowing and preserving the other carbapenems activity. This could be a situation similar to the classical treatment with an amoxicillin-clavulanate combination. Clavulanate
preserves the activity of amoxicillin, as the inhibited -lactamase
has higher affinity for the clavulanate than for the amoxicillin; the
clavulanate is hydrolyzed (suicide inhibitor), and the amoxicillin
is able to act (22). An alternate hypothesis is that there is an initial
reduction in bacterial density by one of the compounds, thus facilitating the activity of the other carbapenem against a reduced
inoculum (23).
Double-carbapenem therapy was tested in chemostat experiments and in an immunocompetent-mouse thigh infection with a
TABLE 1 Recommended doses of ceftazidime and avibactam
Estimated CLCR
(ml/min/1.73 m)a
50
5031
3016
156
6b
Estimated creatinine clearance (CLCR) as determined by using the most recent serum
creatinine value, the patients most recent actual (not ideal) body weight, and the
Cockcroft-Gault formula (30).
b
Both ceftazidime and avibactam are hemodialyzable; thus, ceftazidime-avibactam
should be administered after hemodialysis on hemodialysis days.
c
Given over 120 min at a constant rate of infusion.
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Urine
Blood, sputum,
abdominal wound
Abdominal wound,
blood, urine, CVC
Intestinal transplant
Blood, CVC
Hip joint
replacement
Adenocarcinoma and
hepatocarcinoma
Blood
Renal hematoma
Sputum
Blood
Necrotizing
pancreatitis
Blood
Aortic prosthesis
replacement
Blood, endotracheal
aspirate
Blood, urine
Subarachnoid
hemorrhage
Cerebral hemorrhage
Clinical sample(s)
KPC-producing
K. pneumoniae
KPC-producing
K. pneumoniae
KPC-producing
K. pneumoniae
Carbapenemaseproducing K.
pneumoniae
Carbapenemaseproducing K.
pneumoniae
Carbapenemaseproducing K.
pneumoniae
Pan-drugresistant K.
pneumoniae
KPC-3-producing
K. pneumoniae
KPC-2-producing
K. pneumoniae
KPC-2-producing
K. pneumoniae
KPC-2-producing
K. pneumoniae
Microorganism
Abbreviations: CVC, central venous catheter; ERT, ertapenem; MER, meropenem; DOR, doripenem; CST, colistin; POL-B, polymyxin B; CAZ-AVI, ceftazidime-avibactam.
Ranges are presented when different isolates were isolated and different susceptibility testing MICs were obtained. R, resistant by disc diffusion.
Camargo et al.
(present case
article), United
States
Ceccarelli et al.
(12), Italy
Giamarellou et al.
(11), Greece
Underlying disease(s)
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Reference or source
and country
TABLE 2 Reported clinical cases of double-carbapenem therapy in patients infected with multidrug-resistant and pan-drug resistant K. pneumoniae, including carbapenemase producersa
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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