Choosing the Appropriate Carbapenem for Different Infections

General Principles for Carbapenem Selection

The American College of Critical Care Medicine recommends that carbapenems should not be used as empirical treatment for community-acquired bacterial infections unless specific risk factors are present 1
Carbapenems offer a wide spectrum of antimicrobial activity against gram-positive, gram-negative, and anaerobic pathogens, according to the World Journal of Emergency Surgery 2
The World Journal of Emergency Surgery classifies carbapenems into two main groups: Group 1, which includes ertapenem, active against ESBL-producing pathogens but not active against Pseudomonas aeruginosa or Enterococcus species, and Group 2, which includes imipenem/cilastatin, meropenem, and doripenem, active against non-fermentative gram-negative bacilli including Pseudomonas 2

The Intensive Care Medicine journal suggests that carbapenems should be considered in patients with a known history of colonization/infection by ESBL-producing Enterobacteriaceae or ceftazidime-resistant P. aeruginosa within the last 3 months, plus severe sepsis or septic shock 1
The Intensive Care Medicine journal also recommends considering carbapenems for hospital-acquired severe bacterial infections with at least two of the following: previous treatment with third-generation cephalosporin, fluoroquinolones, or piperacillin-tazobactam in the last 3 months, carriage of ESBL-producing Enterobacteriaceae or ceftazidime-resistant P. aeruginosa within the last 3 months, hospitalization during the last 12 months, patient from nursing facility with indwelling catheter/gastrostomy tube, or ongoing epidemic of multidrug-resistant bacteria in the healthcare institution 1, 3

The Clinical Microbiology and Infection journal notes that meropenem has advantages, including better CNS tolerability than imipenem, slightly greater activity against gram-negative bacilli than imipenem, and can be administered as IV bolus or infusion 4
The World Journal of Emergency Surgery states that ertapenem is good for ESBL-producing Enterobacteriaceae, but lacks activity against Pseudomonas aeruginosa and Enterococcus species 2
The Clinical Microbiology and Infection journal recommends ertapenem for mild to moderately severe intra-abdominal infections without risk of Pseudomonas 5

The Clinical Microbiology and Infection journal suggests considering newer combinations, such as ceftazidime-avibactam for KPC and OXA-48 producers, meropenem-vaborbactam for KPC-producing Enterobacteriaceae, and imipenem-cilastatin-relebactam for certain carbapenem-resistant infections 4, 6
The Journal of Microbiology, Immunology and Infection recommends high-dose extended-infusion meropenem (6g/day, 3-hour infusion) for some carbapenem-resistant Enterobacteriaceae with MICs ≤16 mg/L 4, 7

The Clinical Microbiology and Infection journal recommends a practical algorithm for carbapenem selection, including considering non-carbapenem options for community-acquired infections, and ertapenem or meropenem for hospital-acquired/severe infections 8, 5

Ertapenem does not provide reliable coverage against Corynebacterium species and should not be used when targeting these organisms, according to the Intensive Care Medicine guidelines 9
The American Society for Microbiology recommends considering alternative carbapenems, such as imipenem-cilastatin or meropenem, for broader Gram-positive activity, including coverage of Corynebacterium species 10
Ertapenem demonstrates excellent activity against ESBL-producing Enterobacteriaceae, with a strength of evidence supported by Clinical Microbiology and Infection guidelines 11

The Infectious Diseases Society of America suggests that imipenem-cilastatin or meropenem should be considered instead of ertapenem for nosocomial pathogens and organisms requiring broader Gram-positive coverage, including Corynebacterium species 10