Role of Fosfomycin in Management of Pseudomonas Infections

Clinical Applications and Recommendations

Fosfomycin should primarily be used as part of combination therapy rather than monotherapy for Pseudomonas aeruginosa infections, particularly for carbapenem-resistant strains, due to the high risk of resistance development with monotherapy and improved efficacy when combined with other antipseudomonal agents 1
For carbapenem-resistant P. aeruginosa infections, fosfomycin may be considered as part of combination therapy with agents such as polymyxins, aminoglycosides, or carbapenems 1
Observational studies suggest that fosfomycin-containing combination therapies may reduce mortality in infections caused by multidrug-resistant gram-negative bacteria, though evidence quality is very low 1
Fosfomycin has minimal propensity for collateral damage to intestinal flora, making it advantageous from an antibiotic stewardship perspective 2
Consider fosfomycin as a carbapenem-sparing option in settings with high incidence of carbapenem-resistant P. aeruginosa to reduce selective pressure for carbapenem resistance 3

The bacterial efficacy of fosfomycin is generally lower than that of other first-line agents for uncomplicated infections 2
Fosfomycin susceptibility testing is not routinely performed in many clinical laboratories, which may limit its targeted use 2
Evidence for clinical efficacy against P. aeruginosa infections is primarily based on in vitro and observational studies rather than randomized controlled trials 1