Is Piperacillin-Tazobactam Effective for the Treatment of Pyelonephritis Caused by ESBL-producing Organisms?

Sima L Sharara, Joe Amoah, Zoi D Pana, Patricia J Simner, Sara E Cosgrove, Pranita D Tamma
Clinical Infectious Diseases 2019 December 20

BACKGROUND: Limited data exist regarding the efficacy of piperacillin-tazobactam (TZP) for the management of non-bacteremic pyelonephritis caused by ESBL-producing organisms.

METHODS: We conducted a multicenter observational study comparing clinical outcomes in adults hospitalized with ESBL-producing pyelonephritis receiving TZP versus carbapenems using an inverse probability of treatment weighted propensity score analysis. Patients were eligible for inclusion if all of the following criteria were met: (1) urine cultures growing Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or Proteus mirabilis at ≥50,000 CFU/mL, (2) identification of an ESBL gene by uropathogen; (3) pyuria (≥10 WBC/hpf); and (4) dysuria and fever plus at least one of the following symptoms: emesis, rigors, hypotension, or flank pain.

RESULTS: 186 patients were included in the propensity-score weighted cohort; 45 (24%) received TZP and 141 (76%) received a carbapenem. 27% of patients were admitted to the ICU, 47% were immunocompromised, and 46% of patients had underlying urologic abnormalities. There were no differences between the two groups in the proportion of patients (20% vs. 25%) with recurrent cystitis or pyelonephritis with the same ESBL-producing organism within 30 days (OR 0.75; 95% CI 0.31-1.81, p=0.52). There were no differences in resolution of clinical symptoms by day 7 or 30-day mortality. One (2%) patient in the TZP arm and 11 (8%) patients in the carbapenem arm had incident carbapenem-resistant organisms isolated within 60 days (p=0.09).

CONCLUSION: TZP may be a reasonable alternative to carbapenems for the management of ESBL-producing pyelonephritis and may mitigate the risk of emergence of carbapenem-resistant organisms, compared with carbapenem therapy.

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