Carbapenem-resistant organisms: Difference between revisions

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*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]]
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*For all of the above, also consider: [[eravacycline]], [[tigecycline]], [[colistin]] (though increasing resistance), [[plazomicin]]
  +
*For carbapenem-resistant [[Pseudomonas aeruginosa]], consider: [[cefiderocol]], [[imipenem-relebactam]]
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  +
=== 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]]
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|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]]
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|3 g IV q8h infused over 3 h
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[[Cystitis]]: 1.5 g IV q8h infused over 1 h
  +
|DTR-PA
  +
|-
  +
|[[ciprofloxacin]]
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|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]]
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|1 mg/kg IV q12h
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|CRE, CRAB
  +
|-
  +
|[[ertapenem]]
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|1 g IV q24h infused over 30 min
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|ESBL-E, AmpC-E
  +
|-
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|[[fosfomycin]]
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|[[Cystitis]]: 3 g p.o. once
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|ESBL-E. coli cystitis
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|-
  +
|[[gentamicin]]
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|7 mg/kg IV load then based on PK
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[[Cystitis]]: 5 mg/kg IV once
  +
|ESBL-E, AmpC-, CRE, DTR-PA
  +
|-
  +
|[[imipenem-cilastatin]]
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|ESBL-E or AmpC-E: 500 mg IV q6h infused over 30 min
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CRE and CRAB: 500 mg IV q6h infused over 3 h
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[[Cystitis]]: 500 mg IV q6h infused over 30 min
  +
|ESBL-E, AmpC-E, CRE, CRAB
  +
|-
  +
|[[imipenem-cilastatin-relebactam]]
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|1.25 g IV q6h infused over 30 min
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|CRE, DTR-PA
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|-
  +
|[[levofloxacin]]
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|750 mg p.o./IV q24h
  +
|ESBL-E, AmpC-E, Stenotrophomonas
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|-
  +
|[[meropenem]]
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|ESBL-E or AmpC-E: 1-2 g IV q8h infused over 30 min
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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]]
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|4 g IV q8h infused over 3 h
  +
|CRE
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|-
  +
|[[minocycline]]
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|200 mg IV/p.o. q12h
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|CRAB, Stenotrophomonas
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|-
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|[[nitrofurantoin]]
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|cystitis: macrocystals 100 mg p.o. q12h or oral suspension 50 mg p.o. q6h
  +
|ESBL-E cystitis, AmpC-E cystitis
  +
|-
  +
|[[plazomicin]]
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|15 mg/kg IV load then dosed by PK
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[[Cystitis]]: 15 mg/kg IV once
  +
|ESBL-E, AmpC-E, CRE, DTR-PA
  +
|-
  +
|[[polymyxin B]]
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|
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|DTR-PA, CRAB
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|-
  +
|[[tigecycline]]
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|200 mg IV load followed by 100 mg IV q12h
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|CRE, CRAB, Stenotrophomonas
  +
|-
  +
|[[tobramycin]]
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|7 mg/kg IV load then dosed by PK
  +
[[Cystitis]]: 5 mg/kg IV once
  +
|ESBL-E, AmpC-E, CRE, DTR-PA
  +
|-
  +
|[[co-trimoxazole]]
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|8-12 mg/kg/day (TMP) p.o./IV divided 18-12h
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[[Cystitis]]: 160 mg (TMP) p.o./IV q12h
  +
|ESBL-E, AmpC-E, Stenotrophomonas
 
|}
  
|}
 
[[Category:Bacteria]]
  
[[Category:Bacteria]]

Latest revision as of 08:58, 30 August 2022

Background

  • Mechanisms include decreased expression of porins, increased expression of efflux pumps, and carbapenemases

Management

Antibiotic KPC NDM OXA-48 CRPsA CRAcB Stenotrophomonas
aztreonam-avibactam + + + ± – +
cefiderocol + + + + + +
ceftazidime-avibactam + – + ± – –
ceftolozane-tazobactam – – – ± – ±
eravacycline + + + – + +
fosfomycin ± ± ± ± – –
imipenem-relebactam + – ± + – –
meropenem-vaborbactam + – – – – –
plazomicin + ± + ± – –
colistin ± ± ± ± ± ±
tigecycline + + + – + +

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
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