Impact of Hypoalbuminemia on Ceftriaxone Treatment Failure in Patients With Enterobacterales Bacteremia: A Propensity-Matched, Retrospective Cohort Study

Abstract

Objectives Ceftriaxone is frequently prescribed due to its convenience of dosing and robust antimicrobial activity. However, patients with hypoalbuminemia may experience suboptimal ceftriaxone exposure due to the high degree of protein binding. We aim to evaluate the impact of hypoalbuminemia on treatment failure among hospitalized adults with Enterobacterales bacteremia who received ceftriaxone therapy. Methods We conducted an observational cohort study among patients with Enterobacterales bacteremia that received > 72 hours of ceftriaxone initiated within 48 hours of index culture. A propensity-score model was used to match and compare patients with hypoalbuminemia. The primary outcome was treatment failure defined as a composite of: 1) escalation from ceftriaxone to ertapenem or an intravenous antibacterial agent with activity against Pseudomonas aeruginosa, or 2) inpatient death. Secondary outcomes included hospital length of stay, duration of antibiotic therapy, and time to infection resolution. Results Of 260 patients included, majority of patients developed bacteremia from a urinary source (71.5%), and Escherichia coli was the most common pathogen identified (72.3%). Patients with hypoalbuminemia experienced numerically higher rates of treatment failure, although did not reach statistical significance (12.3% vs. 7.7%, P = 0.21). Among patients receiving care in the intensive care unit, the impact of hypoalbuminemia on treatment failure was more pronounced (24.4% vs. 7.3%, P = 0.07). Conclusions Hypoalbuminemia may not have a significant impact on clinical outcomes among patients with Enterobacterales bacteremia treated with ceftriaxone. However, critically ill patients may be subject to higher incidence of treatment failure in the presence of hypoalbuminemia.

Ertapenem Versus Meropenem for the Treatment of Extended Spectrum Beta-Lactamase-Producing Enterobacterales Bacteremia in Critically Ill Patients

“…11 In a recent observational cohort study, hypoalbuminemia did not appear to affect clinical outcomes for patients with Enterobacterales bacteremia treated with ceftriaxone, but the authors noted that numerically more incidences of treatment failure were observed among critically ill patients with hypoalbuminemia. 12 These studies beg the question if there is a need to consider alternative dosing strategies for ertapenem given the similarities to ceftriaxone. Patients within our cohort were matched in part on lowest albumin at admission, and most patients included were hypoalbuminemic both at admission and at carbapenem initiation.…”