1037. Effect of Oral Step-Down Therapy on Readmission Rates in Escherichia coli Bacteremia

Abstract

Background Escherichia coli is the most common cause of community-acquired bloodstream infections. Fluoroquinolones (FQ) and trimethoprim/sulfamethoxazole (TS) are preferred for oral step-down therapy due to high bioavailability. Antimicrobial stewardship programs commonly restrict FQ use, promoting consideration of non-FQ agents for treatment of sensitive organisms. We hypothesized that oral β-lactams would be non-inferior to FQ and TS with a primary outcome of 30-day all-cause readmission.MethodsThis was a retrospective non-inferiority study that reviewed electronic health records for patients with E. coli bacteremia from January 1, 2016 to December 31, 2017. Exclusion criteria included hospital acquired infections, death during hospitalization and concomitant infections. Patient demographics, Pitt Bacteremia Score, Charleston Comorbidity Index, antibiotic regimen (IV/PO), and readmission were collected. Patients were divided into two groups, oral FQ/TS verses β-lactams. A pretrial noninferiority margin for the primary outcome was set at 3%. Secondary outcomes included 30-day infection and E. coli readmission. Significant risk factors for readmission were entered into a multiple logistic regression model in a forward stepwise approach using SPSS.ResultsDemographics were similar between groups, 57 patients received FQ/TS and 151 received β-lactams. The 30-day-all cause readmission rate was 15.8% and 29.1%, respectively (absolute risk difference 13.3%, CI: 1–25).β-lactams were found to be inferior to FQ/TS for 30-day all-cause readmission. readmission occurred in 5.3% of patients in the FQ/TS group verses 14.6% of patients in the β-lactam group (P = 0.07). E.coli accounted for 100% of the infection-related readmissions in the FQ/ST group and 70% in the β-lactam group. Patients who received a β-lactam antibiotic were more likely to be readmitted then those patients treated with FQ/TS (odds ratio: 2.25, CI: 0.95–5.30, P = 0.06).ConclusionStep-down therapy to oral β-lactams resulted in higher rates of 30-day all-cause and infection-related readmissions in patients with E. coli bacteremia.Disclosures All authors: No reported disclosures.

Oral Fluoroquinolone or Trimethoprim-Sulfamethoxazole vs ß-Lactams as Step-Down Therapy for Enterobacteriaceae Bacteremia: Systematic Review and Meta-analysis

“…Two studies included only cases of urosepsis [6, 12], whereas the remaining 6 included uncomplicated infections from a variety of sources, including urinary (1510 of 2289, or 66% of all infections in total), intraabdominal/biliary, central line infections, skin and soft tissue infections, pneumonia, and unclear sources. Only 1 study included Escherichia coli infections [10], but the rest examined bloodstream infections due to Enterobacteriaceae in general. Most studies [5, 8–10] reported patient outcomes with FQ and TMP-SMX collectively (“high bioavailability group”) vs the oral ß-lactams (“low bioavailability group”), whereas 2 [7, 11] only examined FQs vs ß-lactams.…”

Transition from intravenous to oral antimicrobial therapy in patients with uncomplicated and complicated bloodstream infections

“…Kutob et al demonstrated low 90-day mortality or recurrence in patients with Gram-negative BSI switched to oral levofloxacin (highly bioavailable, once-a-day agent) [36]. Treatment failure rates were higher among oral ciprofloxacin or trimethoprim-sulfamethoxazole (moderate bioavailability, twice a day regimens) and highest for oral b-lactams (low bioavailability, trimethoprim-sulfamethoxazole based on a predefined noninferiority margin [39]. The heterogeneity and small number of patients receiving any particular dose of an oral b-lactam leave a lot to be desired in future investigations.…”

“…a Most commonly used doses are provided as per cited studies in patients with bloodstream infections due to susceptible microorganisms and normal hepatic and renal function.b Includes Enterobacteriaceae, Pseudomonas aeruginosa, and other lactose non-fermenting Gram-negative bacilli. c Includes Enterobacteriaceae and obligate anaerobic bacteria.d All patients in one study[36] and overwhelming majority of those in the other two studies[34,39] had a urinary source of BSI. e May require a loading dose of 400 mg every 12 hours.…”

Significant Publications on Infectious Diseases Pharmacotherapy in 2019

“…[49][50][51][52][53] Other agents included in these studies, such as trimethoprimsulfamethoxazole and b-lactams, have been used in too few patients to draw meaningful conclusions on their effectiveness. [54][55][56][57] In gram-negative BSI complicated by bone and joint infections, oral fluoroquinolones are also a first-line choice due to their high bone penetration. 58 In BSI due to Candida species, studies have demonstrated that it is safe and effective to transition to oral azole therapy once patients meet criteria established from randomized controlled trials, such as bloodstream clearance, clinical improvement, and documented susceptibility to fluconazole or another azole.…”