December 1997

A Randomized, Double-blind Clinical Trial Comparing Cefepime Plus Metronidazole With Imipenem-Cilastatin in the Treatment of Complicated Intra-abdominal Infections

Author Affiliations

From the Departments of Surgery, Cornell University, New York, NY (Dr Barie); University of Florida, Gainesville (Dr Vogel); University of Washington, Seattle (Dr Dellinger); University of Toronto, Toronto, Ontario (Dr Rotstein); University of Cincinnati, Cincinnati, Ohio (Dr Solomkin); and the Bristol-Myers Squibb Pharmaceutical Research Institute, Wallingford, Conn (Drs Yang and Baumgartner). Members of the Cefepime Intra-abdominal Infection Study Group are listed in a box on page 1296. Drs Barie, Dellinger, and Solomkin are consultants to Bristol-Myers Squibb.

Arch Surg. 1997;132(12):1294-1302. doi:10.1001/archsurg.1997.01430360040008

Objective:  To evaluate the safety and efficacy of cefepime hydrochloride plus metronidazole vs the combination of imipenem and cilastatin sodium in the treatment of complicated intra-abdominal infections in adult patients.

Design:  Prospective, randomized, double-blind multicenter study.

Setting:  University-affiliated hospitals in the United States and Canada.

Patients:  Three hundred twenty-three patients with complicated intra-abdominal infections in whom an operative procedure or percutaneous drainage was required for diagnosis and management.

Intervention:  Cefepime, 2 g, was administered intravenously every 12 hours (n=164) in addition to metronidazole, 500 mg (or 7.5 mg/kg) intravenously every 6 hours. Imipenen—cilastatin sodium, 500 mg, was administered intravenously every 6 hours (n= 159). Surgical infection management was determined by the patients' surgeons.

Main Outcome Assessments:  Clinical cure, defined as elimination of all signs and symptoms relevant to the original infection; and treatment failure, defined as persistence, increase or worsening of signs and symptoms resulting in an antibiotic change, requirement of an additional surgical procedure to cure the infection, or a wound infection with fever.

Results:  Of the initial isolates, 84% were susceptible to cefepime and 92% were susceptible to imipenemcilastatin. Among the 217 protocol-valid patients, those treated with cefepime+metronidizole were deemed clinical cures (88%) more frequently than were imipenemcilastatin—treated patients (76%) (P=.02). Using multivariate analysis to adjust for identified clinical risk factors for an adverse outcome (severity of presenting illness, isolation of enterococcus, type of infection, and duration of prestudy hospitalization), there was a trend (P=.06) toward a higher cure rate favoring cefepime+metronidazole. Pathogens were eradicated in significantly (P=.01) more patients treated with combined cefepime and metronidazole (89%) than with imipenem-cilastatin (76%).

Conclusion:  The combination of cefepime plus metronidazole is safe and effective therapy for patients with severe intra-abdominal infections.Arch Surg. 1997;132:1294-1302