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Patient Case CC: Recurrent Cholangitis - #MEDIGRAM

Welcome to the #MEDIGRAM Patient Case: Chief Compliant Series. Short, concise patient cases to foster thought-provoking questions and to challenge you to ask questions! Make sure to by at the end of the week for explanations for the correct/incorrect answers. Discussions open to FREE SUBSCRIBERS ONLY!



Extended-spectrum beta-lactamases are enzymes that certain bacteria produce to hydrolyze extended spectrum cephalosporins. FQ may have activity against ESBL organisms, but in this case, susceptibility panel R to LFX.

IDSA does mention that PIP-TAZ can be considered if improving on therapy for uncomplicated ESBL UTI (high urinary concentrations). However, IDSA recommends carbapenems over PIP-TAZ for non-urinary ESBL infections.

You may see ESBL panels that show PIP-TAZ can be used since it shows susceptible. Should work right? Incorrect clinically. There were higher rates of treatment failure with PIP-TAZ vs meropenem for ESBL bacteremia.

Possible reasons for treatment failure: inaccurate MIC, increased bacterial inoculum, and/or organisms with increased ESBL expression.

Given scarce literature, the above trial (MERINO) has been extrapolated to other serious infections. Ertapenem and meropenem would both technically cover the pathogen. Be a steward and use the more narrow therapy, ertapenem. No need for PsA with meropenem.

An argument against ertapenem would be in the setting of hypoalbuminemia/critically ill possibly increasing mortality compared to meropenem/imipenem-cilastatin. Until more evidence supports this, ertapenem would be the most appropriate therapy.


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