Carbapenem-resistant organisms: Difference between revisions
From IDWiki
(Created page with "== Background == * Mechanisms include decreased expression of porins, increased expression of efflux pumps, and carbapenemases == Management == === Novel Antibiotics ==...") |
m (colour coding) |
||
| (7 intermediate revisions by the same user not shown) | |||
| Line 1: | Line 1: | ||
== |
==Background== |
||
* |
*Mechanisms include decreased expression of porins, increased expression of efflux pumps, and [[carbapenemases]] |
||
== |
==Management== |
||
* See also [[Carbapenem-resistant Enterobacterales]] and ESCMID guidelines[[CiteRef::paul2022eu]] |
|||
=== Novel Antibiotics === |
|||
{| class="wikitable" |
{| class="wikitable" |
||
!Antibiotic |
!Antibiotic |
||
| Line 12: | Line 13: | ||
!OXA-48 |
!OXA-48 |
||
!CRPsA |
!CRPsA |
||
!CRAB |
|||
!CRAcB |
|||
!Stenotrophomonas |
!Stenotrophomonas |
||
|- |
|||
! colspan="7" |New antibiotics |
|||
|- |
|- |
||
|[[aztreonam-avibactam]] |
|[[aztreonam-avibactam]] |
||
| Line 54: | Line 57: | ||
| style="color:darkgreen;text-align:center" | + |
| style="color:darkgreen;text-align:center" | + |
||
| style="color:darkgreen;text-align:center" | + |
| style="color:darkgreen;text-align:center" | + |
||
|- |
|||
|[[fosfomycin]] |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:darkred;text-align:center" |– |
|||
|- |
|- |
||
|[[imipenem-relebactam]] |
|[[imipenem-relebactam]] |
||
| Line 83: | Line 78: | ||
| style="color:goldenrod;text-align:center" |± |
| style="color:goldenrod;text-align:center" |± |
||
| style="color:darkgreen;text-align:center" | + |
| style="color:darkgreen;text-align:center" | + |
||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:darkred;text-align:center" |– |
|||
|- |
|||
! colspan="7" |Old antibiotics |
|||
|- |
|||
|[[fosfomycin]] |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:goldenrod;text-align:center" |± |
| style="color:goldenrod;text-align:center" |± |
||
| style="color:darkred;text-align:center" |– |
| style="color:darkred;text-align:center" |– |
||
| Line 102: | Line 107: | ||
| style="color:darkgreen;text-align:center" | + |
| style="color:darkgreen;text-align:center" | + |
||
| style="color:darkgreen;text-align:center" | + |
| style="color:darkgreen;text-align:center" | + |
||
|- |
|||
|[[polymixins]] |
|||
| style="color:darkgreen;text-align:center" | + |
|||
| style="color:darkgreen;text-align:center" | + |
|||
| style="color:darkgreen;text-align:center" | + |
|||
| style="color:darkgreen;text-align:center" | + |
|||
| style="color:darkgreen;text-align:center" | + |
|||
| |
|||
|- |
|||
|[[aztreonam]] |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:darkred;text-align:center" |– |
|||
| |
|||
|- |
|||
|[[temocillin]] |
|||
| style="color:goldenrod;text-align:center" |± |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:darkred;text-align:center" |– |
|||
| style="color:darkred;text-align:center" |– |
|||
| |
|||
|} |
|} |
||
*For KPC (the most common Class A carbapenemase) consider: [[ceftazidime-avibactam]], [[meropenem-vaborbactam]], [[imipenem-relebactam]], [[cefiderocol]] |
|||
[[Category:Antibiotics]] |
|||
*For AmpCs, consider: [[ceftazidime-avibactam]], [[meropenem-vaborbactam]] |
|||
*For OXA-48-like producers, consider: [[ceftazidime-avibactam]] (preferred), or [[cefiderocol]] |
|||
*For metallo-β-lactamases, consider: [[aztreonam-avibactam]], or [[ceftazidime-avibactam]] plus [[aztreonam]], [[cefiderocol]] |
|||
*For all of the above, also consider: [[eravacycline]], [[tigecycline]], [[colistin]] (though increasing resistance), [[plazomicin]] |
|||
*For carbapenem-resistant [[Pseudomonas aeruginosa]], consider: [[ceftolozane-tazobactam]] (if susceptible), [[cefiderocol]], [[imipenem-relebactam]] |
|||
=== Dosing === |
|||
{| class="wikitable" |
|||
!Antimicrobial |
|||
!Dose |
|||
!Targetted Organisms |
|||
|- |
|||
|[[amikacin]] |
|||
|20 mg/kg IV load then per PK monitoring |
|||
[[Cystitis]]: 15 mg/kg IV once |
|||
|ESBL-E, AmpC-E, CRE, DTR-PA |
|||
|- |
|||
|[[ampicillin-sulbactam]] |
|||
|9 g IV q8h infused over 4 h, or 27 g IV over 24 hours continuous infusion |
|||
|CRAB |
|||
|- |
|||
|[[cefepime]] |
|||
|2 g IV q8h infused over 2 h |
|||
[[Cystitis]]: 1 g IV q8h |
|||
|AmpC-E |
|||
|- |
|||
|[[cefiderocol]] |
|||
|2 g IV q8h infused over 3 h |
|||
|CRE, DTR-PA, CRAB, Stenotrophomonas |
|||
|- |
|||
|[[ceftazidime-avibactam]] |
|||
|2.5 g IV q8h infused over 3 h |
|||
|CRE, DTR-PA |
|||
|- |
|||
|[[ceftazidime-avibactam]] plus [[aztreonam]] |
|||
|2.5 g IV q8h infused over 3 h plus 2 g IV q8h infused over 3 h, infused concurrently if possible |
|||
|MBL CRE, Stenotrophomonas |
|||
|- |
|||
|[[ceftolozane-tazobactam]] |
|||
|3 g IV q8h infused over 3 h |
|||
[[Cystitis]]: 1.5 g IV q8h infused over 1 h |
|||
|DTR-PA |
|||
|- |
|||
|[[ciprofloxacin]] |
|||
|400 mg IV q8-12h or 500-750 mg p.o. q12h |
|||
|ESBL-E, AmpC-E |
|||
|- |
|||
|[[colistin]] |
|||
| |
|||
|CRE cystitis, DTR-PA cystitis, CRAB cystitis |
|||
|- |
|||
|[[eravacycline]] |
|||
|1 mg/kg IV q12h |
|||
|CRE, CRAB |
|||
|- |
|||
|[[ertapenem]] |
|||
|1 g IV q24h infused over 30 min |
|||
|ESBL-E, AmpC-E |
|||
|- |
|||
|[[fosfomycin]] |
|||
|[[Cystitis]]: 3 g p.o. once |
|||
|ESBL-E. coli cystitis |
|||
|- |
|||
|[[gentamicin]] |
|||
|7 mg/kg IV load then based on PK |
|||
[[Cystitis]]: 5 mg/kg IV once |
|||
|ESBL-E, AmpC-, CRE, DTR-PA |
|||
|- |
|||
|[[imipenem-cilastatin]] |
|||
|ESBL-E or AmpC-E: 500 mg IV q6h infused over 30 min |
|||
CRE and CRAB: 500 mg IV q6h infused over 3 h |
|||
[[Cystitis]]: 500 mg IV q6h infused over 30 min |
|||
|ESBL-E, AmpC-E, CRE, CRAB |
|||
|- |
|||
|[[imipenem-cilastatin-relebactam]] |
|||
|1.25 g IV q6h infused over 30 min |
|||
|CRE, DTR-PA |
|||
|- |
|||
|[[levofloxacin]] |
|||
|750 mg p.o./IV q24h |
|||
|ESBL-E, AmpC-E, Stenotrophomonas |
|||
|- |
|||
|[[meropenem]] |
|||
|ESBL-E or AmpC-E: 1-2 g IV q8h infused over 30 min |
|||
CRE and CRAB: 2 g IV q8h infused over 30 min |
|||
[[Cystitis]]: 1 g IV q8h, infused over 30 min |
|||
|ESBL-E, AmpC-E, CRE, CRAB |
|||
|- |
|||
|[[meropenem-vaborbactam]] |
|||
|4 g IV q8h infused over 3 h |
|||
|CRE |
|||
|- |
|||
|[[minocycline]] |
|||
|200 mg IV/p.o. q12h |
|||
|CRAB, Stenotrophomonas |
|||
|- |
|||
|[[nitrofurantoin]] |
|||
|cystitis: macrocystals 100 mg p.o. q12h or oral suspension 50 mg p.o. q6h |
|||
|ESBL-E cystitis, AmpC-E cystitis |
|||
|- |
|||
|[[plazomicin]] |
|||
|15 mg/kg IV load then dosed by PK |
|||
[[Cystitis]]: 15 mg/kg IV once |
|||
|ESBL-E, AmpC-E, CRE, DTR-PA |
|||
|- |
|||
|[[polymyxin B]] |
|||
| |
|||
|DTR-PA, CRAB |
|||
|- |
|||
|[[tigecycline]] |
|||
|200 mg IV load followed by 100 mg IV q12h |
|||
|CRE, CRAB, Stenotrophomonas |
|||
|- |
|||
|[[tobramycin]] |
|||
|7 mg/kg IV load then dosed by PK |
|||
[[Cystitis]]: 5 mg/kg IV once |
|||
|ESBL-E, AmpC-E, CRE, DTR-PA |
|||
|- |
|||
|[[co-trimoxazole]] |
|||
|8-12 mg/kg/day (TMP) p.o./IV divided 18-12h |
|||
[[Cystitis]]: 160 mg (TMP) p.o./IV q12h |
|||
|ESBL-E, AmpC-E, Stenotrophomonas |
|||
|} |
|||
[[Category:Bacteria]] |
|||
Latest revision as of 02:43, 14 November 2024
Background
- Mechanisms include decreased expression of porins, increased expression of efflux pumps, and carbapenemases
Management
- See also Carbapenem-resistant Enterobacterales and ESCMID guidelines1
| Antibiotic | KPC | NDM | OXA-48 | CRPsA | CRAB | Stenotrophomonas |
|---|---|---|---|---|---|---|
| New antibiotics | ||||||
| aztreonam-avibactam | + | + | + | ± | – | + |
| cefiderocol | + | + | + | + | + | + |
| ceftazidime-avibactam | + | – | + | ± | – | – |
| ceftolozane-tazobactam | – | – | – | ± | – | ± |
| eravacycline | + | + | + | – | + | + |
| imipenem-relebactam | + | – | ± | + | – | – |
| meropenem-vaborbactam | + | – | – | – | – | – |
| plazomicin | + | ± | + | ± | – | – |
| Old antibiotics | ||||||
| fosfomycin | ± | ± | ± | ± | – | – |
| colistin | ± | ± | ± | ± | ± | ± |
| tigecycline | + | + | + | – | + | + |
| polymixins | + | + | + | + | + | |
| aztreonam | – | ± | – | ± | – | |
| temocillin | ± | – | – | – | – | |
- For KPC (the most common Class A carbapenemase) consider: ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, cefiderocol
- For AmpCs, consider: ceftazidime-avibactam, meropenem-vaborbactam
- For OXA-48-like producers, consider: ceftazidime-avibactam (preferred), or cefiderocol
- For metallo-β-lactamases, consider: aztreonam-avibactam, or ceftazidime-avibactam plus aztreonam, cefiderocol
- For all of the above, also consider: eravacycline, tigecycline, colistin (though increasing resistance), plazomicin
- For carbapenem-resistant Pseudomonas aeruginosa, consider: ceftolozane-tazobactam (if susceptible), cefiderocol, imipenem-relebactam
Dosing
| Antimicrobial | Dose | Targetted Organisms |
|---|---|---|
| amikacin | 20 mg/kg IV load then per PK monitoring
Cystitis: 15 mg/kg IV once |
ESBL-E, AmpC-E, CRE, DTR-PA |
| ampicillin-sulbactam | 9 g IV q8h infused over 4 h, or 27 g IV over 24 hours continuous infusion | CRAB |
| cefepime | 2 g IV q8h infused over 2 h
Cystitis: 1 g IV q8h |
AmpC-E |
| cefiderocol | 2 g IV q8h infused over 3 h | CRE, DTR-PA, CRAB, Stenotrophomonas |
| ceftazidime-avibactam | 2.5 g IV q8h infused over 3 h | CRE, DTR-PA |
| ceftazidime-avibactam plus aztreonam | 2.5 g IV q8h infused over 3 h plus 2 g IV q8h infused over 3 h, infused concurrently if possible | MBL CRE, Stenotrophomonas |
| ceftolozane-tazobactam | 3 g IV q8h infused over 3 h
Cystitis: 1.5 g IV q8h infused over 1 h |
DTR-PA |
| ciprofloxacin | 400 mg IV q8-12h or 500-750 mg p.o. q12h | ESBL-E, AmpC-E |
| colistin | CRE cystitis, DTR-PA cystitis, CRAB cystitis | |
| eravacycline | 1 mg/kg IV q12h | CRE, CRAB |
| ertapenem | 1 g IV q24h infused over 30 min | ESBL-E, AmpC-E |
| fosfomycin | Cystitis: 3 g p.o. once | ESBL-E. coli cystitis |
| gentamicin | 7 mg/kg IV load then based on PK
Cystitis: 5 mg/kg IV once |
ESBL-E, AmpC-, CRE, DTR-PA |
| imipenem-cilastatin | ESBL-E or AmpC-E: 500 mg IV q6h infused over 30 min
CRE and CRAB: 500 mg IV q6h infused over 3 h Cystitis: 500 mg IV q6h infused over 30 min |
ESBL-E, AmpC-E, CRE, CRAB |
| imipenem-cilastatin-relebactam | 1.25 g IV q6h infused over 30 min | CRE, DTR-PA |
| levofloxacin | 750 mg p.o./IV q24h | ESBL-E, AmpC-E, Stenotrophomonas |
| meropenem | ESBL-E or AmpC-E: 1-2 g IV q8h infused over 30 min
CRE and CRAB: 2 g IV q8h infused over 30 min Cystitis: 1 g IV q8h, infused over 30 min |
ESBL-E, AmpC-E, CRE, CRAB |
| meropenem-vaborbactam | 4 g IV q8h infused over 3 h | CRE |
| minocycline | 200 mg IV/p.o. q12h | CRAB, Stenotrophomonas |
| nitrofurantoin | cystitis: macrocystals 100 mg p.o. q12h or oral suspension 50 mg p.o. q6h | ESBL-E cystitis, AmpC-E cystitis |
| plazomicin | 15 mg/kg IV load then dosed by PK
Cystitis: 15 mg/kg IV once |
ESBL-E, AmpC-E, CRE, DTR-PA |
| polymyxin B | DTR-PA, CRAB | |
| tigecycline | 200 mg IV load followed by 100 mg IV q12h | CRE, CRAB, Stenotrophomonas |
| tobramycin | 7 mg/kg IV load then dosed by PK
Cystitis: 5 mg/kg IV once |
ESBL-E, AmpC-E, CRE, DTR-PA |
| co-trimoxazole | 8-12 mg/kg/day (TMP) p.o./IV divided 18-12h
Cystitis: 160 mg (TMP) p.o./IV q12h |
ESBL-E, AmpC-E, Stenotrophomonas |
References
- ^ Mical Paul, Elena Carrara, Pilar Retamar, Thomas Tängdén, Roni Bitterman, Robert A. Bonomo, Jan de Waele, George L. Daikos, Murat Akova, Stephan Harbarth, Celine Pulcini, José Garnacho-Montero, Katja Seme, Mario Tumbarello, Paul Christoffer Lindemann, Sumanth Gandra, Yunsong Yu, Matteo Bassetti, Johan W. Mouton, Evelina Tacconelli, Jesús Rodríguez-Baño. European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for the treatment of infections caused by multidrug-resistant Gram-negative bacilli (endorsed by European society of intensive care medicine). Clinical Microbiology and Infection. 2022;28(4):521-547. doi:10.1016/j.cmi.2021.11.025.
