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Review
. 2022 Dec 1;35(6):568-574.
doi: 10.1097/QCO.0000000000000884. Epub 2022 Oct 3.

Empirical antibiotic therapy for difficult-to-treat Gram-negative infections: when, how, and how long?

Matteo Bassetti  1   2 , Antonio Vena  1   2 , Laura Labate  1   2 , Daniele R Giacobbe  1   2
Affiliations
Review

Empirical antibiotic therapy for difficult-to-treat Gram-negative infections: when, how, and how long?

Matteo Bassetti et al. Curr Opin Infect Dis. .

Abstract

Purpose of review: To discuss empirical therapy for severe infections due to Gram-negative bacteria with difficult-to-treat resistance (GNB-DTR) in current clinical practice, focusing in particular on the positioning of novel therapeutic agents and rapid diagnostic tests.

Recent findings: The current era of novel agents active against GNB-DTR and showing differential activity against specific determinants of resistance is an unprecedented scenario, in which the clinical reasoning leading to the choice of the empirical therapy for treating severe GNB-DTR infections is becoming more complex, but it also allows for enhanced treatment precision.

Summary: Novel agents should be used in line with antimicrobial stewardship principles, aimed at reducing selective pressure for antimicrobial resistance. However, this does not mean that they should not be used. Indeed, excesses in restrictive uses may be unethical by precluding access to the most effective and less toxic treatments for patients with severe GNB-DTR infections. Given these premises (the 'how'), empirical treatment with novel agents should be considered in all patients with risk factors for GNB-DTR and severe clinical presentation of acute infection (the 'when'). Furthermore, empirical novel agents should preferably be continued only for a few hours, until de-escalation, modification, or confirmation (as targeted therapy) is made possible by the results of rapid diagnostic tests (the 'how long').

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References

    1. Kadri SS, Adjemian J, Lai YL, et al. Difficult-to-treat resistance in Gram-negative bacteremia at 173 US hospitals: retrospective cohort analysis of prevalence, predictors, and outcome of resistance to all first-line agents. Clin Infect Dis 2018; 67:1803–1814.
    1. Bassetti M, Vena A, Sepulcri C, et al. Treatment of bloodstream infections due to Gram-negative bacteria with difficult-to-treat resistance. Antibiotics (Basel) 2020; 9:632.
    1. Baltas I, Stockdale T, Tausan M, et al. Impact of antibiotic timing on mortality from Gram-negative bacteraemia in an English district general hospital: the importance of getting it right every time. J Antimicrob Chemother 2021; 76:813–819.
    1. Bassetti M, Vena A, Giacobbe DR, et al. Ceftolozane/tazobactam for treatment of severe ESBL-producing enterobacterales infections: a multicenter nationwide clinical experience (CEFTABUSE II Study). Open Forum Infect Dis 2020; 7:ofaa139.
    1. Zilberberg MD, Shorr AF, Micek ST, et al. Multidrug resistance, inappropriate initial antibiotic therapy and mortality in Gram-negative severe sepsis and septic shock: a retrospective cohort study. Crit Care 2014; 18:596.

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