Effectiveness of Fosfomycin for the Treatment of Multidrug-Resistant Escherichia coli Bacteremic Urinary Tract Infections: A Randomized Clinical Trial

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2022Author
Sojo Dorado, Jesús
López Hernández, Inmaculada
Rosso Fernández, Clara
Morales, Isabel M.
Palacios Baena, Zaira R.
Hernández Torres, Alicia
Merino de Lucas, Esperanza
Escolà Vergé, Laura
Bereciartua, Elena
García Vázquez, Elisa
Pintado, Vicente
Boix Palop, Lucía
Natera Kindelán, Clara
Sorlí, Luisa
Borrell, Nuria
Giner Oncina, Livia
Amador Prous, Concha
Shaw, Evelyn
Jover, Alfredo
Molina, Jose
Martínez Álvarez, Rosa M.
Dueñas, Carlos J.
Calvo Montes, Jorge
Silva, Jose T.
Cárdenes, Miguel A.
Lecuona, María
Pomar, Virginia
Valiente de Santis, Lucía
Yagüe Guirao, Genoveva
Lobo Acosta, María Angeles
Merino Bohórquez, Vicente
Pascual, Álvaro
Rodríguez Baño, Jesús
Suggested citation
Sojo Dorado, Jesús;
López Hernández, Inmaculada;
Rosso Fernández, Clara;
Morales, Isabel M.;
Palacios Baena, Zaira R.;
Hernández Torres, Alicia;
...
Rodríguez Baño, Jesús.
(2022)
.
Effectiveness of Fosfomycin for the Treatment of Multidrug-Resistant Escherichia coli Bacteremic Urinary Tract Infections: A Randomized Clinical Trial.
Journal of the American Medical Association (JAMA) Netw Open, 2022,vol. 5, núm. 1.
https://doi.org/10.1001/jamanetworkopen.2021.37277.
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Show full item recordAbstract
Importance The consumption of broad-spectrum drugs has increased as a consequence of the spread of multidrug-resistant (MDR) Escherichia coli. Finding alternatives for these infections is critical, for which some neglected drugs may be an option.
Objective To determine whether fosfomycin is noninferior to ceftriaxone or meropenem in the targeted treatment of bacteremic urinary tract infections (bUTIs) due to MDR E coli.
Design, Setting, and Participants This multicenter, randomized, pragmatic, open clinical trial was conducted at 22 Spanish hospitals from June 2014 to December 2018. Eligible participants were adult patients with bacteremic urinary tract infections due to MDR E coli; 161 of 1578 screened patients were randomized and followed up for 60 days. Data were analyzed in May 2021.
Interventions Patients were randomized 1 to 1 to receive intravenous fosfomycin disodium at 4 g every 6 hours (70 participants) or a comparator (ceftriaxone or meropenem if resistant; 73 participants) with the option to switch to oral fosfomycin trometamol for the fosfomycin group or an active oral drug or parenteral ertapenem for the comparator group after 4 days.
Main Outcomes and Measures The primary outcome was clinical and microbiological cure (CMC) 5 to 7 days after finalization of treatment; a noninferiority margin of 7% was considered.
Results Among 143 patients in the modified intention-to-treat population (median [IQR] age, 72 [62-81] years; 73 [51.0%] women), 48 of 70 patients (68.6%) treated with fosfomycin and 57 of 73 patients (78.1%) treated with comparators reached CMC (risk difference, −9.4 percentage points; 1-sided 95% CI, −21.5 to ∞ percentage points; P = .10). While clinical or microbiological failure occurred among 10 patients (14.3%) treated with fosfomycin and 14 patients (19.7%) treated with comparators (risk difference, −5.4 percentage points; 1-sided 95% CI, −∞ to 4.9; percentage points; P = .19), an increased rate of adverse event–related discontinuations occurred with fosfomycin vs comparators (6 discontinuations [8.5%] vs 0 discontinuations; P = .006). In an exploratory analysis among a subset of 38 patients who underwent rectal colonization studies, patients treated with fosfomycin acquired a new ceftriaxone-resistant or meropenem-resistant gram-negative bacteria at a decreased rate compared with patients treated with comparators (0 of 21 patients vs 4 of 17 patients [23.5%]; 1-sided P = .01).
Conclusions and Relevance This study found that fosfomycin did not demonstrate noninferiority to comparators as targeted treatment of bUTI from MDR E coli; this was due to an increased rate of adverse event–related discontinuations. This finding suggests that fosfomycin may be considered for selected patients with these infections.
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Journal of the American Medical Association (JAMA) Netw Open, 2022,vol. 5, núm. 1European research projects
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