From the Guidelines
Ertapenem is not the preferred choice for covering pulmonary ESBL-producing organisms, especially in cases where metallo-β-lactamase (MBL)-producing carbapenem-resistant Enterobacterales (CRE) are suspected, due to its limited activity against these isolates. According to the most recent evidence 1, ceftazidime/avibactam plus aztreonam is the preferred treatment for MBL-producing CRE infections, with cefiderocol being a conditional alternative. Ertapenem, a carbapenem antibiotic, has been widely used for treating infections caused by ESBL-producing Enterobacteriaceae, but its efficacy against MBL-producing CRE is uncertain. The typical adult dosage of ertapenem is 1 gram administered intravenously or intramuscularly once daily, with treatment duration ranging from 7-14 days depending on infection severity. However, due to the emergence of MBL-producing CRE, ertapenem's use should be guided by local epidemiology and susceptibility patterns. Renal dosage adjustments are necessary for patients with creatinine clearance below 30 mL/min.
Some key points to consider when using ertapenem for pulmonary ESBL infections include:
- Ertapenem lacks significant activity against Pseudomonas aeruginosa and Acinetobacter species, so culture results should guide therapy when these pathogens are suspected.
- The decreased susceptibility of some Enterobacteriaceae isolates to ertapenem using new criteria is alarming, particularly for ESBL-producing K. pneumoniae and E. cloacae.
- Local microbiological and clinical outcome data are necessary to support the implementation of new criteria for ertapenem use in clinical practice.
- Ceftazidime/avibactam plus aztreonam is the preferred treatment for MBL-producing CRE infections, with cefiderocol being a conditional alternative.
It is essential to note that the evidence for ertapenem's efficacy against ESBL-producing organisms is based on older studies 1, while the most recent study 1 provides guidance on the treatment of MBL-producing CRE infections. Therefore, the use of ertapenem for pulmonary ESBL infections should be guided by the most recent evidence and local epidemiology.
From the Research
Ertapenem Coverage for Pulmonary ESBL
- Ertapenem has been shown to be effective in treating infections caused by extended-spectrum beta-lactamase (ESBL)-producing organisms, including those causing pulmonary infections 2, 3, 4.
- A study published in 2007 found that ertapenem was effective in treating ventilator-associated pneumonia (VAP) caused by ESBL-producing Gram-negative organisms, with a clinical success rate of 80% and a microbiological success rate of 75% 2.
- Another study published in 2008 found that ertapenem was effective in treating ESBL-positive gram-negative bacteraemia, with a favourable clinical response rate of 96% and an attributable mortality rate of 4% 3.
- A study published in 2012 found that ertapenem was effective as a first-line treatment option for infections caused by ESBL-producing gram-negative bacteria, with a clinical response rate of 78% and a microbiologic cure rate of 92% 4.
- In terms of susceptibility, a study published in 2011 found that ESBL-producing E. coli and Klebsiella spp. strains were highly susceptible to ertapenem, with susceptibility rates of 99.2% and 96.4%, respectively 5.
Limitations and Considerations
- While ertapenem has been shown to be effective in treating ESBL-producing organisms, its use may select for carbapenem-resistant bacteria, including Pseudomonas aeruginosa 6.
- The increasing use of ertapenem has been correlated with an increase in the incidence of carbapenem-resistant E. coli and Klebsiella spp. 6.
- Therefore, the use of ertapenem should be carefully considered and monitored, and alternative treatment options should be explored when possible.