Editorial Commentary – Combination Therapy for Pseudomonas aeruginosa Bacteremia: Where Do We Stand?

February 19, 2017 at 11:42 am

Clinical Infectious Diseases July 15, 2013 V.57 N.2 P.217-220

Mical Paul and Leonard Leibovici

Correspondence: Mical Paul, MD, Unit of Infectious Diseases, Rambam Healthcare Campus, 6 Ha’Aliya Street, Haifa 31096, Israel (m_paul@rambam.health.gov.il).

Substantial evidence from randomized controlled trials (RCTs) refutes an advantage to β-lactam–aminoglycoside combination therapy for sepsis [1]. However, there are gaps in this body of evidence. The number of patients with gram-negative bacteremia evaluated for mortality in all trials to date amounts to fewer than 200 [1]; patients with Pseudomonas aeruginosa bacteremia have not been evaluated separately; and patients with septic shock are usually excluded from RCTs [2]. In general, patients included in RCTs are not representative of the patient population seen in general practice [3]. In this issue of Clinical Infectious Diseases, Peña et al present the first large prospective study of P. aeruginosa bacteremia, specifically addressing the issue of combination therapy versus monotherapy [4]. Special reasons exist for the focus on P. aeruginosa, including the paucity of treatment options, in vitro data suggesting synergy [5], and the high mortality associated with P. aeruginosa bacteremia [6]. Indeed, in Peña’s contemporary cohort, the 30-day mortality following P. aeruginosa bacteremia was 30%.

 

The 2 main reasons quoted in favor of combination therapy for P. aeruginosa bacteremia are to increase the probability of appropriate empirical coverage and to improve overall the antibiotics’ activity through synergism. Peña et al’s study addresses the question of synergy. The authors examined the association of combination therapy with survival among patients when all antibiotics were covering. Both in the empirical and definitive stages of treatment, no significant advantage to combination therapy was observed in this largest cohort to date including 632 episodes of P. aeruginosa …

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http://cid.oxfordjournals.org/content/57/2/217.full.pdf

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Entry filed under: Antimicrobianos, Bacterias, Bacteriemias, Metodos diagnosticos, REPORTS, Resistencia bacteriana, Sepsis, Update.

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