Adult

Carbapenemase-producing Enterobacterales (CPE) treatment

Always discuss with Micro/ ID - not all cases need treatment

Enhanced infection control precautions needed. Inform IPC team.

Ecoli, Klebsiella pneumoniae or other coliforms exhibiting resistance to either ertapenem, meropenem or both are termed carbapenem resistant. This is often due to the presence of carbapenemase enzymes.

  • CPE Colonisation without active infection is NOT an indication for treatment
  • NB when treating true infections due to CPE, higher dosing regimens may be appropriate - follow Micro/ID advice
  • The antibiotics described are RESTRICTED and their use must be discussed with Micro/ID

Lower UTI due to CPE

Treat with an agent to which the organism is susceptible  e.g. nitrofurantoin(50mg po qds)*, pivmecillinam (400mg po for 1 dose, then 200 mg tds), co-trimoxazole (960mg po bd) or  fosfomycin (single 3g oral sachet)

Or, amikacin 15 mg/kg iv single dose (max dose: 1.5g iv od)

*Adverse effects have been reported with nitrofurantoin see Nitrofurantoin MHRA drug safety updates

Urosepsis or pyelonephritis (including BSI) where carbapenemase tests are negative or not available

amikacin 15 mg/kg iv od (max dose: 1.5g iv od). Daily U&Es recommended. See amikacin monograph for dosing and monitoring. 

If susceptible, co-trimoxazole  po or iv 48-60 mg/kg/day in 2-3 divided doses [Note: 60mg/kg of co-trimoxazole is equivalent to 10 mg/kg of the trimethoprim component] or temocillin 2g iv tds can be used for treatment

OR Prolonged infusion of meropenem 2g (given over 3 hours) iv tds (if ertapenem resistant, meropenem susceptible, MIC less than 8.0)

OR Ceftazidime with avibactam (Zavicefta®)  2.5g iv tds +  aztreonam  2g iv tds (max 8g per 24 hours)

Urosepsis or pyelonephritis (including BSI) where carbapenemase tests are known

Infections outside of urinary tract (including BSI and invasive CPE infection) where carbapenemase tests are negative or not available

Resistance to ertapenem and susceptible to meropenem (MIC less than 8): Prolonged infusion of meropenem 2g (given over 3 hours) iv tds. Consider adding second agent for 48 hours then review e.g. amikacin 15mg/kg iv od (max dose: 1.5g iv od)  OR  fosfomycin 4g-8g iv tds

Resistance to ertapenem and meropenem: Ceftazidime with avibactam (Zavicefta®)  2.5g iv tds +  aztreonam 2g iv tds (max 8g per 24 hours)

Intra-abdominal focus only:  tigecycline 100mg iv loading dose, then 50mg iv bd. Consider adding second agent for 48 hours then review e.g. amikacin 15mg/kg iv od (max dose: 1.5g iv od) OR  fosfomycin 4g-8g iv tds

Infections outside of urinary tract (including BSI and invasive CPE) where carbapenemase tests are known

Other potential treatment for Invasive CPE infection

Other agents may be recommended by Micro/ID, usually in combination, including:-

  • colistimethate sodium Loading dose of 9 Million International Units (MIU) iv followed by maintenance dose 3 Million International Units (MIU) iv every 8 hours (see caution below)
  • tigecycline 100mg iv loading dose, then 50mg iv bd
  • fosfomycin 4-8g iv tds

Monotherapy with cefiderocol (2g every 8 hours iv) or Recarbrio® (Imipenem-cilastatin-relebactam)  (1.25g iv qds) is also an option

When prescribing colistimethate sodium:-

  • Ensure daily monitoring of renal function and consult with Micro/ID BEFORE starting
  • Review other nephrotoxic medications
  • Contraindicated in patients with myasthenia gravis

Further Advice

Always discuss treatment with Micro/ID.

Infection control team can be contacted via:

Monday-Friday 8:30am - 5pm: Bleep 1747 

Saturday 9am to 5pm: Bleep 1747 

For IPC advice across all sites after 5pm or on a Sunday: contact the on-call microbiologist via switchboard

 

Guidelines adapted from:

IDSA guidelines

UKCPA Pharmacy network

BSAC/BIA guidelines

Editorial Information

Last reviewed: 01 May 2025