The death of colistin for KPC producers - part 4

This week there are 2 pieces of news on treatment of KPC producers. Taken together with a previous single-center observational study and two RCTs, all of which showed inferiority of colistin based regimens, I feel we can safely sound the death knell for polymyxins as treatment of KPC producers.

Clinical Infectious Diseases has just released advance access on a multicenter evaluation of outcomes for KPC producers treated with either ceftazidime-avibactam or colistin. The article can be found here:

https://academic.oup.com/cid/article-abstract/doi/10.1093/cid/cix783/4103289/Colistin-vs-Ceftazidime-avibactam-in-the-Treatment?redirectedFrom=fulltext

This study evaluated outcomes of 137 patients in the CRACKLE study, sponsored by the NIH via the Antibiotic Resistance Leadership Group. The execution of this study required a huge amount of effort and lead author, David van Duin, deserves credit for getting this study done.

Of the 137 patients with KPC producers, 63 (46%) had bloodstream infection, 30 (22%) had respiratory tract infections and 19 (14%) had UTI. Adjusted 30 day mortality assessment showed that 9% of patients treated with ceftazidime-avibactam died, versus 32% treated with colistin (p=0.0012).

A feature of the study was the use of DOOR analysis, coordinated by Harvard statistician Scott Evans. Using this analysis, the probability of a better outcome on ceftazidime-avibactam vs colistin was 64% (95% CIs 57-71%).

I do not believe we are going to ever see a large RCT "proving" that colistin is inferior to other therapies for KPC producers. The jury, in my mind, is in. Colistin is no longer appropriate first line treatment for KPC producers.

FDA approval in the last week of meropenem-vaborbactam (for UTI) means that US prescribers now have a choice of both ceftazidime-avibactam and meropenem-vaborbactam for KPC producers.

Comments

  1. It would have been useful if MIC values of infecting strains for colistin, avibactam, meropenem and imipenem provided to establish correlation with clinical outcome. Also it would be interesting to know whether strains were tested for MBL production by phenotypic method.

    ReplyDelete

Post a Comment

Popular posts from this blog

Ampicillin and ceftriaxone as first line therapy for enterococcal endocarditis - I don't think so!

New Treatment Options for XDR Acinetobacter

Providing information on optimizing antibiotic use for the ID Physician or Pharmacist