Serious Consequences to the Use of Cephalosporins as the First Line of Antimicrobial Therapy Administered in Hemodialysis Units

Abstract

Background: The dramatic spread of vancomycin-resistant enterococci (VRE) among hemodialysis (HD) patients led to the replacement of vancomycin with cephalosporins as part of the primary empiric therapy for bacterial infections in HD units. The aim of the study was to examine the effects of this new regimen on the colonization rate of resistant bacteria among HD patients. Methods: Rectal swabs were taken from 105 HD patients and 91 control hospitalized patients. Groups were matched for age, sex, nursing home residency and background diseases. Enterococci were tested for vancomycin resistance, Staphylococcus aureus isolates were tested for methicillin resistance (MRSA), and Enterobacteriaceae were tested for extended-spectrum β-lactamase (ESBL) activity. Results: In the HD group 1 VRE, 1 MRSA and 9 ESBL-producing organisms were isolated compared to 1 MRSA and 1 ESBL organism in the control group (p = 0.018 for ESBL). In the year prior to the study, the use of cephalosporins had been enhanced in the HD group compared to the control group (p < 0.001), and in the HD ESBL-positive patients compared to the HD ESBL-negative ones (p = 0.007). The overall use of antibiotics in the control group was the same as in the HD group. In a subanalysis of the HD group alone, the ESBL carriers were older, sicker, used more antibiotics, were hospitalized frequently and had a higher mortality rate, compared to noncarriers. Conclusions: The use of cephalosporins as first-line therapy in HD patients in central Israel reduced the prevalence of VRE colonization but may have contributed to the emergence of ESBL-producing organisms through induction of selection pressure. This may lead to serious complications in the management of these patients.

Epidemiology of bacteremia and factors associated with multi-drug-resistant gram-negative bacteremia in hematopoietic stem cell transplant recipients

“…This is not surprising, since most of our MDR Gram-negative isolates were enterobacteria-producing ESBL, a mechanism of resistance that may be induced by the exposure to this class of antibiotics. [28][29][30] The other risk factor for MDR Gram-negative bacteremia found in the present study was being at a specific HSCT center. Interestingly, in that particular center no patient was exposed to third-generation cephalosporins.…”

Staphylococcus aureus Infections in Hemodialysis

“…Clearance of cephazolin was significantly higher in high-flux hemodialysis than in conventional hemodialysis, but, in both groups, a dose of 15 to 20 mg/kg resulted in trough levels well above the MIC for a 2-to 3-d period (105). Some limited and poorly powered data suggest an increased occurrence of infections with extended-spectrum ␤-lactamaseproducing organisms, when cephazolin is routinely used in the hemodialysis setting (106).…”

Multidrug‐Resistant Organisms in Dialysis Patients

“…Exposure to antibiotics has consistently been associated with colonization and infection with MDROs, including MRSA, VRE, and MDR‐GNB, in a variety of populations, including dialysis patients . This is a particularly important risk factor in the dialysis population because of the high rate of exposure to antimicrobials within this group.…”