Carbapenem-resistant organisms
From IDWiki
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 | + | + | + | – | + | + |
- 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: 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 |
