2024 IDSA CRAB建議治療策略

Summary of Treatment Strategies for Carbapenem-Resistant Acinetobacter baumannii (CRAB) Infections

Preferred Agents

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1. Sulbactam-Durlobactam:
   • Preferred regimen for CRAB infections.
   • Administer in combination with a carbapenem (e.g., imipenem-cilastatin or meropenem).
2. High-Dose Ampicillin-Sulbactam:
   • Alternative option when sulbactam-durlobactam is unavailable.
   • Dosing: 9g of sulbactam component daily, in combination with at least one other agent (e.g., polymyxin B, minocycline, or cefiderocol).

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2. Additional Agents

1. Polymyxins:
   • Polymyxin B preferred over colistin for systemic infections due to a more favorable PK profile.
   • Use colistin only for UTI.
2. Tetracycline Derivatives:
• Minocycline:
  • Preferred over tigecycline due to clinical experience and CLSI breakpoints (MIC ≤4 µg/mL for susceptibility).
  • Dosing: 200 mg IV or orally every 12 hours.
• Tigecycline:
  • Alternative option with high-dose regimen: 200 mg IV loading dose, followed by 100 mg IV Q12H.
  • Generally effective, but high MICs (>1 µg/mL) limit its efficacy.
• Both should be used in combination therapy.
3. Cefiderocol:
   • Reserve for refractory CRAB infections or when other agents are intolerable or unavailable.
   • Always use as part of combination therapy to prevent resistance development.

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3. Agents Not Recommended

1. Rifamycins:
   • Rifampin and other rifamycins are not suggested due to lack of proven clinical benefit and significant toxicities.
2. Nebulized Antibiotics:
   • Not recommended for respiratory CRAB infections due to inconsistent efficacy, poor lung distribution, and potential respiratory complications.
3. Carbapenems Alone:
   • Meropenem and imipenem-cilastatin are not effective as monotherapy but may be used in combination with sulbactam-durlobactam.

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4. Combination Therapy Recommendations

• Examples of combination regimens:
  • Sulbactam-Durlobactam + Imipenem-Cilastatin/Meropenem.
  • High-Dose Ampicillin-Sulbactam + Polymyxin B/Minocycline/Cefiderocol.

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Key Takeaways

• Prioritize sulbactam-based therapies: Sulbactam-durlobactam is preferred; high-dose ampicillin-sulbactam is a reliable alternative.
• Use combination regimens: Especially in severe infections, to maximize treatment efficacy and prevent resistance.
• Reserve certain agents: Cefiderocol and polymyxins should be reserved for refractory or specific cases.
• Avoid monotherapy and agents with limited evidence (e.g., rifamycins, nebulized antibiotics) to ensure optimal clinical outcomes.