The death of polymyxins for KPC - part 1

Is there still a role for colistin or polymyxin B in the treatment of KPC producers?

There is a plethora of articles examining treatment of KPC producers. Most now conclude that a combination of a polymyxin with other antibiotics is more effective than use of a polymyxin alone.

Based on a single center experience, recently made available online by Antimicrobial Agents and Chemotherapy, the place of polymyxins as firstline therapy for KPC producers is looking very doubtful . This article looked at treatment of bloodstream infection due to carbapenem resistant Klebsiella pneumoniae at the University of Pittsburgh Medical Center. Importantly, it was observational, not a RCT.

Clinical success was defined at 30 days as survival, resolution of signs and symptoms of infection, sterilization of blood cultures within 7 days of treatment initiation, and absence of recurrent infections. A good choice of endpoints. 85% (11/13) patients treated with ceftazidime-avibactam had clinical success compared to 48% (12/25) treated with the combination of a carbapenem and an aminoglycoside and 40% (12/30) treated with a combination of a carbapenem and a polymyxin.

30 day survival rates were 92% (12/13) treated with ceftazidime-avibactam and 69% (66/96) treated with other regimens.

Acute kidney injury was seen in 18% patients treated with ceftazidime-avibactam and 57% treated with the combination of a carbapenem and a polymyxin.

This data is certainly against ongoing use of polymyxins for KPC producers. Expect to see more data from multi-site studies evaluating this question soon. It would be good to see the inferiority of polymyxins confirmed in a RCT, although I fear this will now never happen.

A tentative RIP for polymyxins for KPC, in my opinion.

This article can be found here: http://aac.asm.org

 Ceftazidime-avibactam is superior to other treatment regimens against carbapenem-resistant Klebsiella pneumoniae bacteremia 

 Antimicrob. Agents Chemother. Accepted manuscript posted online 30 May 2017 



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