How to de-escalate Merrem (Meropenem) antibiotics?

From the Guidelines

To deescalate from Merrem (meropenem), it is recommended to discontinue combination therapy within the first few days in response to clinical improvement and/or evidence of infection resolution, as suggested by the Surviving Sepsis Campaign guidelines 1. When deescalating antibiotics, it is essential to consider the clinical improvement of the patient and the evidence of infection resolution. The guidelines suggest that an antimicrobial treatment duration of 7 to 10 days is adequate for most serious infections associated with sepsis and septic shock 1.

• Key factors to consider when deescalating antibiotics include:
  • Clinical improvement of the patient
  • Evidence of infection resolution
  • Culture and sensitivity results to guide the transition to a narrower-spectrum antibiotic
  • Daily assessment for de-escalation of antimicrobial therapy in patients with sepsis and septic shock 1
• The use of procalcitonin levels can also support shortening the duration of antimicrobial therapy in sepsis patients and discontinuation of empiric antibiotics in patients who initially appeared to have sepsis, but subsequently have limited clinical evidence of infection 1. Deescalation should be done after clinical improvement is observed, typically after 48-72 hours of effective therapy, and the patient should be monitored closely for 24-48 hours after deescalation to ensure continued clinical improvement 1.
• It is crucial to involve infectious disease specialists when managing complex infections to ensure the most appropriate deescalation strategy.
• The principle behind deescalation is antimicrobial stewardship - using the most targeted therapy possible to effectively treat the infection while preserving broader agents for when they're truly needed.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

De-escalation of Meropenem

• De-escalation of meropenem is often advocated to reduce the use of broad-spectrum antibiotics in critically ill patients 2.
• A study found that empirical prescription of meropenem was de-escalated in 42% of patients, and patients in whom antibiotics were de-escalated had a trend toward a lower mortality rate 2.
• Reasons for not de-escalating included the absence of conclusive microbiology and colonization with multiresistant gram-negative organisms (MRGN) 2.

Strategies for De-escalation

• A structured stewardship initiative focused on meropenem de-escalation was developed, which included a local guideline for review and de-escalation of meropenem 3.
• The guideline outlined clinical and microbiological criteria that, when met, should lead to a recommendation for meropenem de-escalation 3.
• Targeted carbapenem de-escalation stewardship activity based on pre-determined criteria can effectively and safely reduce meropenem use in the acute hospital setting 3.

Clinical Use of Meropenem

• Meropenem is a broad-spectrum antibacterial agent of the carbapenem family, indicated as empirical therapy prior to the identification of causative organisms, or for disease caused by single or multiple susceptible bacteria in both adults and children with a broad range of serious infections 4.
• The daily dose of meropenem commonly ranges from 3 to 6 g/day, and therapeutic drug monitoring (TDM) can help to maximize the clinical outcomes of the treatment with meropenem 5.
• TDM data can help to adjust the treatment and aid clinical outcomes by indicating the appropriate dosage and preventing failure, toxicity, and possible antimicrobial resistance 5.

Outcomes of De-escalation

• Appropriate meropenem de-escalation in patients with febrile neutropenia is safe and can result in improved clinical outcomes, including lower 30-day all-cause mortality and shorter hospital length of stay 6.
• De-escalation was associated with lower rates of Clostridioides difficile infection (CDI) and more frequent consultations by infectious diseases physicians 6.
• Logistic regression model demonstrated that positive culture, including positive blood culture, and graft-versus-host disease (GVHD) were associated with high rates of appropriate de-escalation, while immunosuppression was associated with lower rates of appropriate de-escalation 6.