Maybe ESBL ignorance truly is stewardship bliss?

Reviewed by Jen Cihlar, DO, Vanderbilt University Medical Center

Bottom line: Removing ESBL status labels from urine culture reports in non-bacteremic patients and just reporting out MICs was shown to reduce use of carbapenems for initial definitive treatment of urinary tract infections without significant impact in clinical outcomes.

In this retrospective cohort study, across a network of 7 community hospitals, ESBL designation was hid after September 2022 from automated susceptibility system, still reporting resistant MICs and MICs of susceptible cefepime and piperacillin/tazobactam isolates in consideration for continued use based on 2023 IDSA guidelines of ESBL and simple cystitis if clinically improving. Menendez and colleagues found a significant decrease in the rate of carbapenem prescribing for initial definitive treatment of ESBL enterobacterales UTI after susceptibilities released for at least 48 hours in non-bacteremic patients 6 months immediately pre- and post-removal (156/199 (78%) vs 93/153 (61%); P<0.01) which was a 40% decrease (P<0.01) in total days of therapy with carbapenem as initial definitive therapy. No significant difference in secondary endpoints of clinical cure rate, infection relapse, readmission, all cause in hospital mortality, length of stay or rate of guideline-compliant therapy. Limitations of this study include challenges with lack of clear documentation delineating cystitis vs pyelonephritis in about ¼ of infections limiting understanding of appropriateness of therapy and comfort level with non-carbapenems prescribing. It is unclear how this stewardship tactic would affect infection prevention isolation practices.

Menendez Alvarado LR, Margulis Landayan A, Williams KN, Frederick CM, Zhang Z, Gauthier TP. Impact of removing ESBL status labelling from culture reports on the use of carbapenems for non-bacteraemic patients diagnosed with ESBL-positive urinary tract infections. Journal of Antimicrobial Chemotherapy. Published online 2024. doi:10.1093/jac/dkae135

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