
==== Front
Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24646
Letter to the Editor
Management of CRE Infections: High Time for an RCT?
Kundu Riddhi 1https://orcid.org/0000-0001-6222-1974

Chowdhury Sumit R 2https://orcid.org/0000-0002-2544-7314

1 Department of Critical Care Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
2 Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
Riddhi Kundu, Department of Critical Care Medicine, Ruby Hall Clinic, Pune, Maharashtra, India, Phone: +91 9650813320, e-mail: riddhi.aiims@gmail.com
5 2024
30 4 2024
28 5 516517
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Kundu R, Chowdhury SR. Management of CRE Infections: High Time for an RCT? Indian J Crit Care Med 2024;28(5):511.

Keywords

Antibacterial
Antibiotic-resistance
Carbapenem-resistant enterobacterales
==== Body
pmc Dear Editor,

We read with interest the study by Vijayakumar et al.1 on the comparative efficacy of Ceftazidime-Avibactam (CAZ-AVI) with or without aztreonam (AZT) vs polymyxins for the treatment of carbapenem-resistant enterobacteriaceae (CRE) infections.

We would like to congratulate the authors for this much-needed study, and it definitely adds to the ever-increasing evidence favoring the CAZ-AVI aztreonam combination over polymyxins in treating NDM and OXA-48 strains, which seems to be the predominant subtype in our country.2

However, we felt certain aspects of the study need further review. One of the primary outcomes of the study included clinical success on day 14. This was defined as patient survival, hemodynamic stability, or an improvement of their SOFA scores on day 14. Improvement of the SOFA scores was defined as a fall in SOFA score by 1 point when baseline SOFA was <3, and a drop in SOFA scores >30% when SOFA was more than 3. The demographic data outlined in Table 1 shows that patients in the Polymyxin group have higher baseline SOFA scores compared to the CAZ-AVI ± AZT group [(6 vs 9); p = 0.09]. We wonder if this could have led to a better outcome in terms of the clinical success in the CAZ-AVI ± AZT group, given that they would need a lower absolute SOFA score change to be labeled as a clinical success due to their lower baseline SOFA scores, to begin with.

Interestingly, there was no difference in other secondary outcomes including 14- and 28-day mortality, days free from mechanical ventilation, ICU and hospital length of stay, and incidence of renal failure. While chasing mortality as an endpoint in ICU trials has its own pitfalls, it's disappointing that the better clinical cure did not translate into better mortality outcomes for this cohort. Finally given the small sample size of the study, the possibility of inflated effect size remains.3

We would nonetheless laud the authors for the valuable insights of this study. A well-designed RCT perhaps is much needed to put all speculations to rest regarding the efficacy of CAZ-AVI ± AZT when compared to polymyxins in the treatment of CRE strains prevalent in this part of the world.

Orcid

Riddhi Kundu https://orcid.org/0000-0001-6222-1974

Sumit R Chowdhury https://orcid.org/0000-0002-2544-7314

Source of support: Nil

Conflict of interest: None
==== Refs
References

1. Vijayakumar M Selvam V Renuka MK Rajagopalan RE The comparative efficacy of ceftazidime–avibactam with or without aztreonam vs polymyxins for carbapenem-resistant enterobacteriaceae infections: A prospective observational cohort study Indian J Crit Care Med 2023 27 12 923 929 10.5005/jp-journals-10071-24577 38074953
2. Prayag PS Patwardhan SA Panchakshari S Sambasivam R Dhupad S Soman RN et al. Ceftazidime-avibactam with or without Aztreonam vs Polymyxin-based combination therapy for carbapenem-resistant enterobacteriaceae: A retrospective analysis Indian J Crit Care Med 2023 27 6 444 450 10.5005/jp-journals-10071-24481 37378372
3. Button KS Ioannidis JP Mokrysz C Nosek BA Flint J Robinson ES et al. Power failure: Why small sample size undermines the reliability of neuroscience Nat Rev Neurosci 2013 14 5 365 376 10.1038/nrn3475 23571845
