What is the recommended treatment for Enterobacter cloacae infections?

Treatment of Enterobacter cloacae Infections

Ceftazidime-avibactam or meropenem-vaborbactam are the preferred treatment options for Enterobacter cloacae infections, particularly for carbapenem-resistant strains. 1

First-line Treatment Options

The treatment approach for E. cloacae infections should be guided by the site of infection, severity, and local resistance patterns:

For Susceptible E. cloacae:

• Ceftazidime-avibactam (2.5g IV q8h) - Recommended for most infections including complicated UTIs (7-14 days) 1
• Meropenem-vaborbactam (4g IV q8h) - Particularly effective for complicated UTIs (7-14 days) 1

For Carbapenem-Resistant E. cloacae:

• KPC-producing strains: Ceftazidime-avibactam or meropenem-vaborbactam 1
• OXA-48-producing strains: Ceftazidime-avibactam 1
• MBL-producing strains: Ceftazidime-avibactam plus aztreonam 1

Treatment by Infection Site

Complicated Intra-abdominal Infections (cIAI)

• AVYCAZ (ceftazidime-avibactam) 2.5g IV q8h plus metronidazole 0.5g IV q8h for 5-14 days 2
  • Clinical cure rates for E. cloacae with this regimen were 84.6% in clinical trials 2
  • FDA-approved for E. cloacae cIAI in adults and pediatric patients 2

Complicated Urinary Tract Infections (cUTI)

• Ceftazidime-avibactam 2.5g IV q8h for 7-14 days 1, 2
• FDA-approved for E. cloacae cUTI in adults and pediatric patients 2

Hospital-acquired/Ventilator-associated Pneumonia (HABP/VABP)

• Ceftazidime-avibactam 2.5g IV q8h for 7-14 days 2
• FDA-approved for E. cloacae HABP/VABP in adults and pediatric patients 2

Alternative Treatment Options

When first-line agents cannot be used:

• Cefepime with metronidazole (for mixed infections) 1
• Imipenem-cilastatin-relebactam 1
• Tigecycline (particularly for intra-abdominal infections) 1

Special Considerations

Extended-Spectrum Beta-Lactamase (ESBL) Producing Strains

• Carbapenems have shown better outcomes than non-carbapenem beta-lactams for ESBL-producing E. cloacae bacteremia 3
• Lower breakthrough bacteremia rates with carbapenem therapy (9.6%) compared to non-carbapenem beta-lactams (58%) 3

Pediatric Dosing

For patients 2 years to <18 years with normal renal function:

• AVYCAZ 62.5 mg/kg (maximum 2.5g) IV q8h over 2 hours 2
• For cIAI, add metronidazole 2

Important Clinical Pearls

1. Always obtain cultures before initiating antibiotics to guide definitive therapy 1

2. Monitor clinical response within 48-72 hours and consider follow-up blood cultures for bloodstream infections 1

3. Susceptibility testing is crucial due to the increasing prevalence of resistant E. cloacae strains 1

4. Dosage adjustment is required in renal impairment for all recommended antibiotics 2

5. Treatment duration varies by infection site:

   • cIAI: 5-14 days
   • cUTI: 7-14 days
   • HABP/VABP: 7-14 days 1, 2

By following these evidence-based recommendations and considering local resistance patterns, clinicians can optimize treatment outcomes for patients with E. cloacae infections.