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Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials

BACKGROUND: The increasing incidence of multidrug-resistant Gram negatives, such as carbapenem-resistant Enterobacteriaceae (CRE), has resulted in a critical need for new antimicrobials. Most studies of new antimicrobials have been performed in patients with nondrug-resistant pathogens. We performed...

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Autores principales: Alexander, Elizabeth L., Loutit, Jeffery, Tumbarello, Mario, Wunderink, Richard, Felton, Tim, Daikos, George, Fusaro, Karen, White, Dan, Zhang, Shu, Dudley, Michael N.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2017
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451664/
https://www.ncbi.nlm.nih.gov/pubmed/28584849
http://dx.doi.org/10.1093/ofid/ofx063
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author Alexander, Elizabeth L.
Loutit, Jeffery
Tumbarello, Mario
Wunderink, Richard
Felton, Tim
Daikos, George
Fusaro, Karen
White, Dan
Zhang, Shu
Dudley, Michael N.
author_facet Alexander, Elizabeth L.
Loutit, Jeffery
Tumbarello, Mario
Wunderink, Richard
Felton, Tim
Daikos, George
Fusaro, Karen
White, Dan
Zhang, Shu
Dudley, Michael N.
author_sort Alexander, Elizabeth L.
collection PubMed
description BACKGROUND: The increasing incidence of multidrug-resistant Gram negatives, such as carbapenem-resistant Enterobacteriaceae (CRE), has resulted in a critical need for new antimicrobials. Most studies of new antimicrobials have been performed in patients with nondrug-resistant pathogens. We performed a retrospective analysis of patients with CRE infections to inform the design of phase 3 clinical trials. METHODS: This was a retrospective study at 22 centers in 4 countries. Baseline data, treatment, and outcomes were collected in patients with complicated urinary tract infection (cUTI)/acute pyelonephritis (AP), hospital-acquired bacterial pneumonia (HABP), ventilator-associated bacterial pneumonia (VABP), and bacteremia due to CRE. RESULTS: Two hundred fifty-six cases of CRE infection were identified: 75 cUTI/AP, 21 HABP, 20 VABP, and 140 bacteremia. The patient population had significant comorbidities: 32.8% had chronic renal insufficiency, and 26.2% were immunocompromised. Illness severity at presentation was high: 29.3% presented with septic shock. Treatment regimens varied widely; however, a majority of patients received combination therapy. Outcomes were universally poor (28-day mortality was 28.1%) across all sites of infection, particularly in dialysis patients and those with sepsis. CONCLUSIONS: The CRE infections occured in patients with substantial comorbidities and were associated with high mortality and low rates of clinical cure with available antibiotics. Patients with these comorbidities are often excluded from enrollment in clinical trials for registration of new drugs. These results led to changes in the inclusion/exclusion criteria of a phase 3 trial to better represent the patient population with CRE infections and enable enrollment. Observational studies may become increasingly important to guide clinical trial design, inform on the existing standard of care, and provide an external control for subsequent trials.
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spelling pubmed-54516642017-06-05 Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials Alexander, Elizabeth L. Loutit, Jeffery Tumbarello, Mario Wunderink, Richard Felton, Tim Daikos, George Fusaro, Karen White, Dan Zhang, Shu Dudley, Michael N. Open Forum Infect Dis Major Article BACKGROUND: The increasing incidence of multidrug-resistant Gram negatives, such as carbapenem-resistant Enterobacteriaceae (CRE), has resulted in a critical need for new antimicrobials. Most studies of new antimicrobials have been performed in patients with nondrug-resistant pathogens. We performed a retrospective analysis of patients with CRE infections to inform the design of phase 3 clinical trials. METHODS: This was a retrospective study at 22 centers in 4 countries. Baseline data, treatment, and outcomes were collected in patients with complicated urinary tract infection (cUTI)/acute pyelonephritis (AP), hospital-acquired bacterial pneumonia (HABP), ventilator-associated bacterial pneumonia (VABP), and bacteremia due to CRE. RESULTS: Two hundred fifty-six cases of CRE infection were identified: 75 cUTI/AP, 21 HABP, 20 VABP, and 140 bacteremia. The patient population had significant comorbidities: 32.8% had chronic renal insufficiency, and 26.2% were immunocompromised. Illness severity at presentation was high: 29.3% presented with septic shock. Treatment regimens varied widely; however, a majority of patients received combination therapy. Outcomes were universally poor (28-day mortality was 28.1%) across all sites of infection, particularly in dialysis patients and those with sepsis. CONCLUSIONS: The CRE infections occured in patients with substantial comorbidities and were associated with high mortality and low rates of clinical cure with available antibiotics. Patients with these comorbidities are often excluded from enrollment in clinical trials for registration of new drugs. These results led to changes in the inclusion/exclusion criteria of a phase 3 trial to better represent the patient population with CRE infections and enable enrollment. Observational studies may become increasingly important to guide clinical trial design, inform on the existing standard of care, and provide an external control for subsequent trials. Oxford University Press 2017-06-01 /pmc/articles/PMC5451664/ /pubmed/28584849 http://dx.doi.org/10.1093/ofid/ofx063 Text en © The Author 2017. Published by Oxford University Press on behalf of Infectious Diseases Society of America. http://creativecommons.org/licenses/by/4.0 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Major Article
Alexander, Elizabeth L.
Loutit, Jeffery
Tumbarello, Mario
Wunderink, Richard
Felton, Tim
Daikos, George
Fusaro, Karen
White, Dan
Zhang, Shu
Dudley, Michael N.
Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials
title Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials
title_full Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials
title_fullStr Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials
title_full_unstemmed Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials
title_short Carbapenem-Resistant Enterobacteriaceae Infections: Results From a Retrospective Series and Implications for the Design of Prospective Clinical Trials
title_sort carbapenem-resistant enterobacteriaceae infections: results from a retrospective series and implications for the design of prospective clinical trials
topic Major Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451664/
https://www.ncbi.nlm.nih.gov/pubmed/28584849
http://dx.doi.org/10.1093/ofid/ofx063
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