Empiric therapy

Carbapenem Resistant Enterobacterales (K. pneumoniae, E. coli)

  1. Treatment options when carbapenemase testing result is available are given in Table.


    2. Available treatment options for carbapenem resistant enterobacterales in India
    Carbapenemase  
    Metallo-β-lactamase (eg. NDM) 1st Choice: Prolonged infusion of ceftazidime-avibactam and aztreonam (over 3 hours)*
    Other options:
    1. Polymyxins (Do-not use polymyxin B for UTI) plus other agent to which organism has demonstrated susceptible MIC (like tigecycline, aminoglycosides, IV fosfomycin) or high dose carbapenems if MIC < 16
    2. Tigecycline (approved for intra-abdominal infection and skin –soft tissue infection)- DO-NOT use for blood stream infection or pneumonia as a standalone agent
    3. Aminoglycosides (for uncomplicated infections like UTI, any other infection for which source reduction has been done)
    Metallo-β-lactamase (eg. NDM) + OXA-48 1st Choice: Prolonged infusion of ceftazidime-avibactam and aztreonam (over 3 hours)*
    Other options:
    1. Polymyxins (do-not use polymyxin B for UTI) plus other agent to which organism has demonstrated susceptible MIC (like tigecycline, aminoglycosides, IV fosfomycin) or high dose carbapenems if MIC < 16
    2. Tigecycline (approved for intra-abdominal infection and skin –soft tissue infection)- DO-NOT use for blood stream infection or pneumonia as a standalone agent
    3. Aminoglycosides (for uncomplicated infections like UTI, any other infection for which source reduction has been done)
    OXA-48 like 1st Choice: Prolonged Infusion of ceftazidime-avibactam**
    Other options:
    1. Polymyxins (do-not use polymyxin B for UTI) plus other agent to which organism has demonstrated susceptible MIC (like tigecycline, aminoglycosides, IV fosfomycin) or high dose carbapenems if MIC < 16
    2. Tigecycline (approved for intra-abdominal infection and skin –soft tissue infection)- DO-NOT use for blood stream infection or pneumonia as a standalone agent
    3. Aminoglycosides (for uncomplicated infections like UTI, any other infection for which source reduction has been done)
    KPC 1st Choice: Prolonged Infusion of ceftazidime-avibactam **
    Other options:
    1. Polymyxins (do-not use polymyxin B for UTI) plus other agent to which organism has demonstrated susceptible MIC (like tigecycline, aminoglycosides, IV fosfomycin) or high dose carbapenems if MIC < 16
    2. Tigecycline (approved for intra-abdominal infection and skin –soft tissue infection)- DO-NOT use for blood stream infection or pneumonia as a standalone agent
    3. Aminoglycosides (for uncomplicated infections like UTI, any other infection for which source reduction has been done)

    *Ceftazidime-avibactam + aztreonam: Perform a synergy test and demonstrate zone of inhibition. Prolonged infusion over 3 hours yields best result. This combination is not well studied in pediatric situations, de-ranged creatinine clearance and CNS infections. (Consultation with an Infectious Disease Physician or a physician having experience in treating such infection is advised)
    ** Ceftazidime-avibactam alone: Apart from carbapenemase test; in-vitro susceptibility testing is recommended prior to use.

  2. Treatment options when Carbapenemase testing result is not available

    1. Polymyxins (do-not use polymyxin B for UTI) plus other agent to which organism has demonstrated susceptible MIC (like tigecycline, aminoglycosides, IV fosfomycin) or high dose carbapenems if MIC < 16
    2. Ceftazidime-avibactam alone if in-vitro susceptibility has been demonstrated or in combination with aztreonam if synergy test is demonstrating zone of inhibition.
    3. Tigecycline (approved for intra-abdominal infection and skin –soft tissue infection)- DO-NOT use for blood stream infection or pneumonia as a standalone agent
    4. Polymyxins (do-not use polymyxin B for UTI) as a single agent (for uncomplicated infections like UTI, any other infection for which source reduction has been done and patient is hemodynamically stable)
    5. Aminoglycosides (for uncomplicated infections like UTI, any other infection for which source reduction has been done)