Extended-Spectrum -Lactamases in Multidrug-Resistant Escherichia coli: Changing the Therapy for Hospital-Acquired and Community-Acquired Infections

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Abstract
Physicians rely on clinical experience and published guidelines to assist with choices in empirical therapy for community-acquired infections. For the treatment of bacteremic urinary tract infections, therapeutic guidelines often include advanced-generation cephalosporins or fluoroquinolones [1]. In this issue of Clinical Infectious Diseases, Rodríguez-Baño et al. [2] report 43 prospectively observed cases of extended-spectrum β-lactamase (ESBL)–producing Escherichia coli bloodstream infection. These represented 8.8% of all cases of E. coli bacteremia detected over a 4-year period at the Hospital Universitario Virgen Macarena, a 950-bed teaching hospital in Seville, Spain. The most common ESBL detected was of the CTX-M type, which was present in 70% of the cases. Predictably, patients who had bacteremia due to ESBL-producing E. coli possessed significant comorbidities. Overall, these patients were elderly (median age, 71 years) and male (70%) and had comorbidities of malignancies (44%), obstructive diseases of the urinary tract (40%), urinary catheters (33%), and venous catheters (47%). Previous use of antimicrobials was also prevalent: 72% of patients received antibiotics before presentation, and 59% of the patients received either a fluoroquinolone or an oxyimino-cephalosporin. Twenty-two cases (51%) of infection were community acquired, with urinary and biliary tracts as the sources of bacteremia. Empirical therapy was inappropriate in 49% of cases. The crude mortality rate was 24% for nosocomial bloodstream infection and 29% for health care–related bloodstream infection. Fortunately, mortality was not associated with the strictly community-acquired isolates.

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