| Summary: | Carbapenems are beta-lactam antibiotics with a very broad spectrum of activity and act by disrupting the synthesis of bacterial cell walls. Others in the family of beta-lactam antibiotics are cephalosporins, which include cefepime and ceftazidime. In contrast, beta-lactamase inhibitors have little antibacterial activity alone. They include tazobactam and clavulanate. When used with beta-lactams however, the combination therapy provides enhanced and extended spectrum of activity against bacteria containing plasmid-mediated and chromosomal beta-lactamases. In the literature, the terminology "combination therapy" varies. For instance, the combination product piperacillin-tazobactam is often referred to as monotherapy unless combined with other agents such as amikacin or tobramycin. The growing problem of multi-drug resistance (MDR) worldwide has led to efforts in restricting the use of carbapenems. MDR and gram-negative bacterial infections are especially predominant in febrile neutropenia (FN), where over 50% of patients have an established or occult infection, and over 20% have bacteremia. If FN patients are not treated immediately, bacterial infections become rapidly fatal. In such patient populations, there are questions of how carbapenems fit in the context of care given the availability of alternative therapies such as beta-lactam/ beta-lactamase inhibitor combinations, and the different strategies of implementation such as escalation and de-escalation. Escalation begins with monotherapy and escalates to a regimen with a broader spectrum. De-escalation begins with a broad regimen and de-escalates to a regimen with a narrower spectrum after laboratory confirmation of the pathogen. The purpose of this report is to review evidence-based guidelines on the appropriate indications or circumstances for the use of carbapenems and other empiric therapies in the context of MDR infections and FN.
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