Can ertapenem be used to treat achromobacter species infections?

Can ertapenem be used to treat achromobacter species infections?

Comment by InpharmD Researcher

Although carbapenems are reported to be effective against Achromobacter infections, there is a lack of literature specifically demonstrating the use of ertapenem. Some literature reports a lack of activity of ertapenem against Achromobacter xylosoxidans. One case report documented the use of ertapenem for Achromobacter bacteremia. The treatment was initially successful, however, the patient experienced a recurrence of Achromobacter bacteremia and was rehospitalized in the following months, requiring alternative treatment.

Background

A 2020 review described treatment options for Achromobacter infection. Carbapenems, as well as trimethoprim-sulfamethoxazole, ceftazidime, and piperacillin are reported to be the most active agents against Achromobacter isolates. In a series of case reports with 10 cancer patients with Achromobacter bacteremia, favorable clinical outcomes were observed with B-lactams, although none of these patients were treated with ertapenem specifically. Carbapenems should be spared where possible because extended-spectrum B-lactamases (ESBL), AmpC type b-lactamases, and metallo-B-lactamases (MBL) have been detected in Achromobacter isolates which appear to contribute to resistance to B-lactams. [1] A 2015 review reported that all carbapenems appear to be active against Achromobacter xylosoxidans except ertapenem. [2]

Literature Review

A search of the published medical literature revealed 2 studies investigating the researchable question:

Can ertapenem be used to treat achromobacter species infections?

Level of evidence

D - Case reports or unreliable data Read more→

Please see Tables 1-2 for your response.

Recurrent Achromobacter Xylosoxidans Bacteremia in a Patient with Pulmonary Extra-Nodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue Type
Design	Case report
Case presentation	A 45 year old male in remission for pulmonary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (EMZL of MALT) and common variable immune deficiency presented with recurrent Achromobacter xylosoxidans bacteremia with symptoms: worsening bilateral lower limb swelling, warmth, erythema, pain, fever (103°F,) elevated HR (112 bpm), hypotension (BP 78/46), and leukocytosis (WBC 10.6 k/uL, lactate 3.9 mmol/L). No injury or open wounds were present in lower extremities. The patient was treated empirically with piperacillin/tazobactam and vancomycin while waiting for cultures. IV fluids and norepinepherine were given for septic shock. Due to persistent fever and bacteremia after days of empiric treatment, therapy was switched to ertapenem. Symptoms and bacteremia resolved and patient was discharged with a regimen of long-course antibiotics. The patient was rehospitalized months later for A. xylosoxidans bacteremia recurrence. The patient was started on chronic suppressive therapy with trimethoprim/sulfamethoxazole. after which he remained asymptomatic with no recurrence of A. xylosoxidans bacteremia.
Study Author Conclusions	This case report consolidates the association between EMZL of MALT and AX colonization. It also suggests the possible involvement of AX in the pathogenesis of EMZL of MALT.

References:

Afzal S, Saleem T, Abdelghaffar B. Recurrent achromobacter xylosoxidans bacteremia in a patient with pulmonary extra-nodal marginal zone lymphoma of mucosa-associated lymphoid tissue type. CHEST. 2020;158(4):1561A. doi: 10.1016/j.chest.2020.08.1401

Meropenem-Resistant Achromobacter Xylosoxidans, Subspecies Denitrificans Bacteremia in a Patient With Stage IV Adenocarcinoma of the Lung
Design	Case report
Case presentation	A 77-year-old male with a past medical history of chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and stage IV adenocarcinoma of the lung, with metastatic disease to the brain and bone, presented to the hospital with severe mouth pain and odynophagia in 2020. Ten days prior to admission, the patient had completed his second round of chemotherapy consisting of gemcitabine, paclitaxel, and bevacizumab. The patient presented with severe stomatitis, dry mucous membranes, a white plaque on the tongue, tenderness to palpation in the lower abdominal quadrants, and 2+ pitting edema in bilateral lower extremities. Portable chest film showed a diffuse coarsened interstitial pattern and a small right upper lobe density. Computed tomography (CT) scan of the abdomen and pelvis with contrast revealed inflammatory changes and thickening in the ascending colon extending into the transverse colon. Stool polymerase chain reaction (PCR) detected Salmonella javiana. With a presumptive diagnosis of neutropenic enterocolitis, the patient was treated with meropenem 1 g every eight hours, fluid resuscitation, and a subcutaneous insulin regimen with filgrastim 300 mcg added on day 3. On hospital day 7, the patient was transferred to the intensive care unit (ICU) due to septic shock. Repeated blood cultures revealed gram-negative bacilli growth. The patient's condition continued to worsen with the development of acute renal failure, worsening encephalopathy, and respiratory failure. After his death, the ICU cultures results revealed multidrug-resistant Achromobacter xylosoxidans, subspecies denitrificans bacteremia. The microbiological sensitivity analysis of the A. xylosoxidans species: sensitive (levofloxacin, trimethoprim/sulfamethoxazole), intermediate (ciprofloxacin, gentamicin, tetracycline, tobramycin), resistant (cefepime, meropenem, piperacillin-tazobactam).
Study Author Conclusions	Advanced systemic infections caused by multidrug-resistant bacteria continue to be a growing concern, especially in high-risk individuals. Infection due to A. xylosoxidans can be life-threatening in neutropenic patients with cancer-related immunosuppression. Despite A. xylosoxidans reported susceptibility to carbapenems and anti-pseudomonal penicillins, these empiric agents alone may not be appropriate in a subset of patients. If promptly reported, antibiotic coverage should be altered based on available in vitro susceptibility testing. Future studies on this rare Gram-negative bacillus are needed to further discern ideal initial therapy. Antibiotic combinations, guided by an infectious disease specialist, may be a more prudent treatment rather than a single reserved antibiotic alone in patients with refractory sepsis. This is especially true in patients whose microbiological sensitivity patterns are not yet available.

References:

Agassi AM, Pollock E, Carter MM, Sherertz RJ, Mangano AP. Meropenem-Resistant Achromobacter xylosoxidans, Subspecies Denitrificans Bacteremia in a Patient With Stage IV Adenocarcinoma of the Lung. Cureus. 2021 Jun 9;13(6):e15546. doi: 10.7759/cureus.15546. PMID: 34277171; PMCID: PMC8269378