What is the treatment for Extended-Spectrum Beta-Lactamase (ESBL) producing Escherichia coli (E. coli)?

From the Guidelines

For the treatment of ESBL-producing E. coli infections, carbapenems are the preferred first-line treatment, with options including meropenem (1g IV every 8 hours), doripenem (500mg IV every 8 hours), or imipenem/cilastatin (1g IV every 8 hours) 1. The choice of empiric antibiotic regimens in patients with intra-abdominal infections (IAIs) should be based on the clinical condition of the patients, the individual risk for infection by resistant pathogens, and the local resistance epidemiology 1. In critically ill patients, antimicrobial therapy should be started as soon as possible, and the selection of a pharmacological agent with penetration to the site of presumed infection is necessary 1. Carbapenem-sparing treatment should be recommended, particularly in settings where there is a high incidence of carbapenem-resistant K. pneumoniae 1. Some key points to consider in the treatment of ESBL-producing E. coli infections include:

• The use of carbapenems as first-line treatment for serious infections
• The consideration of piperacillin-tazobactam or cefepime with metronidazole as alternative options in certain cases
• The importance of antibiotic susceptibility testing to guide therapy
• The need for carbapenem-sparing treatment in settings with high rates of carbapenem resistance
• The potential use of newer antibiotics, such as ceftolozane/tazobactam or ceftazidime/avibactam, in the treatment of IAIs caused by multidrug-resistant Gram-negative bacteria 1. In patients at risk for infection with community-acquired ESBL-producing Enterobacteriaceae, meropenem (1g IV every 8 hours), doripenem (500mg IV every 8 hours), or imipenem/cilastatin (1g IV every 8 hours) may be warranted 1. The treatment duration for ESBL-producing E. coli infections varies by infection site, with 7-14 days recommended for most infections, depending on the severity and site of infection 1. It is essential to note that the treatment of ESBL-producing E. coli infections requires a comprehensive approach, taking into account the severity of the infection, the patient's clinical condition, and the local resistance epidemiology 1.

From the FDA Drug Label

1. 1 Intra-abdominal Infections Piperacillin and tazobactam for injection is indicated in adults and pediatric patients (2 months of age and older) for the treatment of appendicitis (complicated by rupture or abscess) and peritonitis caused by beta-lactamase producing isolates of Escherichia coli
2. 4 Female Pelvic Infections Piperacillin and tazobactam for injection is indicated in adults for the treatment of postpartum endometritis or pelvic inflammatory disease caused by beta-lactamase producing isolates of Escherichia coli.

Treatment of ESBL E. coli

• Piperacillin and tazobactam for injection is indicated for the treatment of infections caused by beta-lactamase producing isolates of Escherichia coli, which includes ESBL E. coli.
• The dosage for adult patients with indications other than nosocomial pneumonia is 3.375 g every six hours [totaling 13.5 g (12 g piperacillin/1.5 g tazobactam)], to be administered by intravenous infusion over 30 minutes 2.
• The recommended duration of piperacillin and tazobactam for injection treatment is from 7 to 10 days 2.

From the Research

Treatment Options for ESBL E. coli Infections

• Carbapenems, such as meropenem and imipenem, are generally considered the antibiotics of choice for the treatment of serious ESBL infections 3.
• However, due to the emergence of carbapenem resistance, alternative treatments are being explored, including cephamycins, fluoroquinolones, and β-lactam/β-lactam inhibitor combinations, such as piperacillin/tazobactam 3, 4.
• Fosfomycin, nitrofurantoin, and pivmecillinam have been shown to be effective against ESBL-producing E. coli in urinary tract infections 4, 5.
• Piperacillin-tazobactam may be a suitable alternative to carbapenems for non-severe cases of ESBL-producing E. coli bacteremia in areas with low frequency of OXA-1 co-production 6.

Considerations for Treatment

• The choice of treatment should be based on the severity of the infection, the susceptibility of the organism, and the local epidemiology of antibiotic resistance 3, 6.
• Optimized dosing of piperacillin/tazobactam, such as high doses and extended infusion, may be necessary to ensure effective treatment 3.
• The use of carbapenems should be reserved for patients with serious infections, while alternative treatments may be considered for patients with milder presentations 3, 7.

Alternative Treatments

• Fosfomycin tromethanol has been shown to be effective in the treatment of complicated lower urinary tract infections caused by ESBL-producing E. coli, and may be a cost-effective alternative to carbapenems 5.
• Other alternative treatments, such as ceftolozane/tazobactam, ceftazidime/avibactam, cefiderocol, and plazomicin, may be considered for patients with ESBL-producing E. coli infections, although more data are needed to fully evaluate their effectiveness 3, 7.