From the Guidelines
Prophylactic treatment for ESBL exposure is not recommended due to the risk of promoting antibiotic resistance and the lack of evidence supporting its effectiveness in preventing infection. The management of intra-abdominal infections, as suggested by the 2016 WSES consensus conference 1, emphasizes the importance of considering local ecology and the potential for anti-ESBL-producer coverage, but this does not imply prophylactic treatment for exposure. Instead, it highlights the need for tailored antibiotic regimens based on the severity and type of infection, as well as local resistance patterns.
When considering the treatment of infections caused by ESBL-producing organisms, a carbapenem-sparing regimen is preferred to reduce the selective pressure that contributes to the emergence of carbapenem-resistant Enterobacteriaceae (CRE) 1. Key points to consider in the management of potential ESBL infections include:
- Monitoring for signs of infection rather than treating prophylactically
- Using carbapenems as first-line agents for confirmed ESBL infections, with alternatives based on susceptibility testing
- Implementing standard infection prevention measures such as hand hygiene and contact precautions to reduce the spread of resistant organisms
- Avoiding the inappropriate use of carbapenems to mitigate the risk of carbapenem resistance
The increasing prevalence of ESBL-producing Enterobacteriaceae in both nosocomial and community-acquired infections, as noted in the Study for Monitoring Antimicrobial Resistance Trends (SMART) program 1, underscores the importance of judicious antibiotic use and infection control practices. By adopting a cautious approach to antibiotic treatment and focusing on evidence-based management strategies, healthcare providers can help preserve the effectiveness of available antibiotics and reduce the morbidity, mortality, and impact on quality of life associated with ESBL infections.
From the Research
Treatment of ESBL Infections
The decision to treat ESBL exposure prophylactically depends on various factors, including the severity of the infection, the source of the infection, and the patient's overall health.
- The use of carbapenems, such as meropenem and imipenem, is generally recommended for the treatment of serious ESBL infections 2.
- However, the increasing emergence of carbapenem resistance has led to a search for effective alternatives, including carbapenem-sparing regimens such as cephamycins, fluoroquinolones, and β-lactam/β-lactam inhibitor combinations 2, 3.
- Ceftolozane-tazobactam and ceftazidime-avibactam have been identified as potential carbapenem-sparing therapies for the treatment of ESBL infections 3, 4.
- Ertapenem has been shown to be effective as a first-line treatment option for infections caused by ESBL-producing gram-negative bacteria, with clinical response and microbiologic cure rates similar to those achieved with group 2 carbapenems 5.
- Patient and infection-specific characteristics should be taken into account when selecting a treatment option, with factors such as the severity of the infection, the source of the infection, and the patient's overall health influencing the choice of therapy 6.
Carbapenem-Sparing Regimens
Carbapenem-sparing regimens, such as β-lactam/β-lactam inhibitor combinations, may be considered as an alternative to carbapenems for the treatment of ESBL infections.
- Piperacillin-tazobactam has been shown to be effective in certain situations, such as step-down therapy or for low-to-moderate severity infections originating from urinary or biliary sources 4.
- Cefepime has been identified as a potential carbapenem-sparing alternative for the treatment of infections caused by AmpC-producing Enterobacteriaceae 6.
- New β-lactams/β-lactamase inhibitors, such as cefepime-enmetazobactam and ceftaroline fosamil-avibactam, are also being investigated as potential treatment options for ESBL infections 4.