IDSA updates guidance on resistant gram-negative infections
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Key takeaways:
- The IDSA updated its treatment guidance on the most common antimicrobial-resistant gram-negative infections.
- The rapid evolution of antimicrobial resistance motivated the IDSA to update the guidelines annually.
The Infectious Diseases Society of America has updated its guidance on the treatment of antimicrobial-resistant gram-negative infections and said it aims to update the guidelines annually to keep up with evolving resistance and new research.
“Novel mechanisms of resistance are being identified at an alarming pace, and the advancement of anti-infectives to treat antimicrobial-resistant infections is impressive,” Pranita D. Tamma, MD, MHS, associate professor of pediatrics and director of the pediatric antimicrobial stewardship program at Johns Hopkins University School of Medicine, told Healio.
The new guidance includes sections on extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), AmpC beta-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales, Pseudomonas aeruginosa with difficult-to-treat resistance, carbapenem-resistant Acinetobacter baumannii (CRAB) and Stenotrophomonas maltophilia.
We asked Tamma, one of six authors of the guidance, about the significance of the new update. Her responses have been lightly edited for length and clarity.
Healio: What prompted the new guidance?
Pranita D. Tamma: Because of the rapid progress [of antimicrobial resistance (AMR) evolution and research], we believe it is essential for the AMR guidance to be updated on an annual basis to keep medical specialists informed of all the rapidly occurring changes. The goal is to publish a new version of the IDSA AMR treatment guidance on an annual basis.
Healio: Why were these specific infections chosen for the update?
Tamma: We chose to focus on the most commonly encountered AMR pathogens in both community hospitals and academic medical centers. There are some AMR infections like those caused by ESBL-producing Enterobacterales or Pseudomonas aeruginosa with difficult-to-treat resistance that are problematic in hospitals of all sizes.
There are other AMR infections, however, like [New Delhi metallo-beta-lactamase]-producing infections, that impact some hospitals more than others. We decided to focus on a comprehensive group of AMR pathogens that are concerning in the United States to make the IDSA guidance as comprehensive as possible.
Healio: What are the most significant updates?
Tamma: Changes were made to nearly all questions in the IDSA guidance. We added a section at the beginning of the document that highlights major changes comparing the 2024 and 2023 IDSA AMR guidance document.
Perhaps one of the most significant changes is the suggested approach to manage CRAB infections. In 2023, a new antibiotic named sulbactam-durlobactam was approved by the FDA. The preclinical and clinical data supporting sulbactam-durlobactam for the treatment of CRAB infections are very favorable. Therefore, the CRAB treatment section has been revised significantly to include sulbactam-durlobactam as the preferred agent for the treatment of CRAB infections.
Healio: Transitioning to oral therapy whenever and as soon as possible has been a topic of discussion in recent years. How does the new guidance treat this?
Tamma: We agree that it is exciting to see a general movement toward transitioning patients to oral antibiotic therapy whenever possible. This approach has the potential to reduce health care costs, duration of hospital stays, and general inconvenience for patients — without compromising patient outcomes.
The importance of transitioning from IV to oral antibiotic therapy is no different for infections caused by AMR organisms. The beginning of the AMR guidance includes a section titled, “Duration of Therapy and Transitioning to Oral Therapy.” In this section, it is specifically stated that “whenever possible, transitioning to oral therapy should be considered (assuming IV therapy was initially prescribed), particularly if the following criteria are met: 1) susceptibility to an appropriate oral agent is demonstrated; 2) the patient is hemodynamically stable; 3) reasonable source control measures have occurred; and 4) concerns about insufficient intestinal absorption are not present.”
Healio: How large an issue is failing to properly distinguish between colonization and infection?
Tamma: A major challenge for clinicians — particularly when glucose non-fermenting gram-negative organisms such as Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia are recovered — is distinguishing colonization and infection. In an effort to promote antibiotic stewardship and reduce unnecessary antibiotic usage that exposes patients to unnecessary toxicities and a furthering of antibiotic resistance, the IDSA AMR guidance stresses the importance of distinguishing between bacterial colonization and infection.
The IDSA guidance also stresses that the decision to target treatment for organisms like CRAB and/or S. maltophilia in empiric antibiotic regimens should involve a careful risk-benefit analysis after reviewing previous culture results, clinical presentation, individual host risk factors and antibiotic-specific adverse event profiles, so as to limit unnecessary antibiotic usage.
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