The 2021 ESCMID guidelines provide updates on the use of targeted antibiotics for the treatment of third-generation cephalosporin-resistant enterobacterales (3GCephRE). This article covers the key recommendations from the guidelines.

Antibiotic-resistant bacteria

Antibiotic-resistant bacteria are a significant cause of infections and deaths, with a majority of the cases and deaths caused by multidrug-resistant gram-negative bacteria (MDR-GNB). The 2021 European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines provide updates on the use of targeted antibiotic treatment for third-generation cephalosporin-resistant Enterobacterales (3GCephRE). The guideline discusses the benefits of individual antibiotics as well as the scope of combination therapy versus monotherapy.

Treatment recommendations for 3GCephRE

Carbapenems such as imipenem or meropenem are recommended as targeted therapy in patients with bloodstream infections (BSI) and severe infection due to 3GCephRE. Ertapenem instead of imipenem or meropenem can be used in BSI due to 3GCephRE without septic shock.

Stepdown targeted therapy is suggested in patients stabilized following carbapenems use. Stepdown targeted therapy should include (based on the susceptibility pattern of the isolate):

• Old β-lactam/β-lactamase inhibitors (BLBLI)
• Quinolones, cotrimoxazole or other antibiotics

Considering antibiotic stewardship considerations, new BLBLI antibiotics should be avoided in infections caused by 3GCephRE. Its use should be reserved for extensively resistant bacteria.

Tigecycline is not recommended for infections caused by 3GCephRE. Cephamycins (e.g. cefoxitin, cefmetazole, flomoxef) and cefepime are also not recommended for 3GCephRE infections.

There is a lack of evidence for the use of cefoperazone-sulbactam, ampicillin-sulbactam, ticarcillin-clavulanic acid, temocillin and mecillinam in patients with 3GCephRE infections. Hence, they are currently not recommended.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.