Thread by @davidvanduin

1/n @ESCMID guidelines are wonderful resource for clinicians treating MDR GNR infections. Great work @jesusrbano @EveTacconelli and many others!
let's compare to @IDSAInfo guidance (paraphrased recs prn). starting w/ 3GcephR-E
idsociety.org/practice-guide… &
idsociety.org/practice-guide…

https://twitter.com/ABsteward/status/1471437030370467842

2/n
First, @IDSAInfo AMR guidance is explicitly "guidance" not a guideline.
Second, @IDSAinfo focuses on treatment recommendations for antimicrobial resistant infections in the United States.

3/n
Now, let's look at specific recommendations (I will follow order in @ESCMID document).

@ESCMID provides several recommendations for Enterobacterales resistant to 3rd gen. cephalosporins. In @IDSAInfo separate recs are provided for ESBL-producers vs. AmpC producers.

4/n
Same approach to severe ESBL-E infection
@ESCMID: For patients with BSI and severe infection due to 3GCephRE, we recommend a carbapenem as targeted therapy.

@IDSAInfo: A carbapenem is preferred for the treatment of infections outside of the urinary tract caused by ESBL-E.

5/n
ps @IDSAInfo for AmpC: Cefepime is suggested for the treatment of infections caused by organisms at moderate to high risk of significant AmpC production (i.e., E. cloacae, K. aerogenes, and C. freundii) when the cefepime MIC is ≤2 mcg/mL. -continued-

6/n
(ampC continued) A carbapenem is recommended when the cefepime MIC is ≥4 mcg/mL, assuming carbapenem susceptibility is demonstrated, as ESBL co-production may be present.

7/n
@ESCMID: For patients with BSI due to 3GCephRE without septic shock, ertapenem instead of imipenem or meropenem may be used
@IDSAInfo: ertapenem not separately mentioned
#IDTwitter important to separate ertapenem in guidance?

8/n
@ESCMID: For patients with low-risk, non-severe infections due to 3GCephRE, we suggest piperacillin-tazobactam, amoxicillin/clavulanic acid or quinolones
@IDSAInfo: carbapenems, quinolones, trimethoprim-sulfa are preferred treatment options for ESBL-E pyelonephritis & cUTI

9/n
main differences for low-risk ESBL-E infection:
@ESCMID: pip/tazo is OK.
@IDSAInfo: Piperacillin-tazobactam should be avoided for the treatment of infections caused by ESBL-E

10/n
amox/clav is mentioned as an alternative in the uncomplicated cystitis section of @IDSAInfo guidance

11/n
@ESCMID: For cUTI without septic shock, we conditionally recommend aminoglycosides for short durations of therapy, or IV fosfomycin
@IDSAInfo: carbapenems, quinolones, trimethoprim-sulfa are preferred treatment options for ESBL-E pyelonephritis & cUTI

12/n
ps @IDSAInfo: Amox-clav, single-dose aminoglycosides, & oral fosfomycin are alternative options for ESBL-E cystitis.

pps no IV fosfo in US

13/n
@ESCMID: Among all patients with 3GCephRE infections, stepdown targeted therapy following carbapenems once patients are stabilized, using old BLBLIs, quinolones, cotrimoxazole or other antibiotics based on the susceptibility pattern of the isolate, is good clinical practice

14/n
@IDSAInfo: The role of oral step-down therapy for ESBL-E non-urinary infections has not been formally evaluated. However, oral step-down therapy has been shown to be a reasonable treatment consideration for Enterobacterales bloodstream infections

15/n
@IDSAInfo specifically mentions quinolones and trimethoprim-sulfamethoxazole as reasonable options for oral step-down.

16/n
@ESCMID: We do not recommend tigecycline for infections caused by 3GCephRE
@IDSAInfo: tigecycline not specifically mentioned but not recommended for any type of ESBL-E or AmpC-E infection.

17/n
@ESCMID: new BLBLIs are reserve antibiotics for extensively-resistant bacteria and therefore, we consider it good clinical practice to avoid their use for infections caused by 3GCephRE
@IDSAInfo: new BLBLIs not addressed in ESBL-E section. In AmpC section -continued-

18/n
@IDSAInfo: Despite the increased potency of new BLBLI against AmpC-E infections compared with piperacillin-tazobactam, the panel suggests that these agents be preferentially reserved for treating infections caused by organisms exhibiting carbapenem resistance

19/n
@ESCMID: We suggest that cephamycins (e.g. cefoxitin, cefmetazole, flomoxef) and cefepime not be used for 3GCephRE infections.
@IDSAInfo: cephamycins not addressed in ESBL-E section.

20/n That summarizes the comparison of the 3rd generation cephalosporin resistant enterobacterales @ESCMID recs. Overall, mostly consistent with @IDSAInfo guidance (not surprisingly as based on the same evidence).

21/21
Might do the same comparison for CRE, pseudomonas, and CRAB @ESCMID vs @IDSAInfo recs on another day (or maybe @ClancyNeil or @OncIDPharmd wants to take that on???)