SPICE?
Today in Dr. HPK's morning report we discussed a very interesting case of sepsis secondary to a line infection. In this case the blood cultures were positive for both Serratia and E.coli. This brought up an interesting management question which we posed to the senior residents in the room:
What antimicrobial would you select empirically for such a patient?
There are a couple of questions to consider when faced with this particular management question:
1.) What is SPICE?
SPICE refers to a group of organisms that have a chromosomal beta-lactamase gene called ampC. This beta-lactamase is active against beta-lactam antibiotics including cephalosporins, penicillin, and piperacillin/tazobactam. The interesting point about this class of organisms is that they will produce the beta-lactamase enzyme only when stimulated by the presence of the antibiotic, hence the term "inducible".
The induced enzyme will be released into the periplasmic space and "eat up" the antibiotic, rendering it ineffective, resulting in treatment failure.
SPICE stands for: Serratia, Providencia, Indole-positive Proteus species, Citrobacter, and Enterobacter. There are other gram negatives that have inducible beta-lactamase genes, but these are the most widely known species.
Providencia
Indole-positive Proteus species
Citrobacter
Enterobacter
 |
| The various mechanisms that gram-negative bacteria can develop antibiotic resistance (NEJM, 2010) |
2.) What antibiotics can I use to treat SPICE organisms?
The most important point to consider, is the avoidance of beta-lactam antibiotics.
 |
| Beta-Lactam ring |
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| Ceftriaxone - can you see the beta-lactam ring? |
Classes of antibiotics that do not induce the ampC gene include the following antibiotics:
TMP / SMX (Septra) - oral / IV
Carbapenems (i.e. Meropenem) - IV
Aminoglycosides (i.e. gentamycin) - IV
Fluoroquinolones (i.e. moxifloxacin) - oral / IV
 |
| Comparison (by me): of the commonly used antibiotics to treat SPICE organisms |
If a patient is septic (or for severe infections), than empiric therapy with an intravenous carbapenem is the ideal choice.
Consultation with an Infectious Diseases specialist and discussion with Antimicrobial Stewardship is also advisable in these cases.
Please check out the Antimicrobial Stewardship Website from UHN/MSH for more details, It is an amazing resource related to infections and antibiotics and can be accessed via mobile devices!
For further reading:
Hospital-Acquired Infections Due to Gram-Negative Bacteria. Anton Y. Peleg, M.B., B.S., M.P.H. and David C. Hooper, M.D. The New England Journal of Medicine. 2010 May 13; 362(19): 1804–1813.
http://m.antimicrobialstewardship.com/clinical_summaries/index.php
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