Empirical therapy of CRE

• Only polymyxins ensure sufficient coverage for all resistance mechanisms of CRE; hence, the preferred empirical regimen.
• Fosfomycin and new BL/BLI (zaviceta) do not have sufficient coverage to ensure good empirical cover for CRE as mono-therapy.
• Combination therapy would be preferred in all severe infections-carbapenem/minocycline+polymyxins.

Targeted therapy of CRE

• Look at meropenem MIC and preferably genotype the carbapenemases.
• If no NDM: go for CEF-AVI testing and use it.
• If NDM: Go for combination therapy with polymyxins-carbapenem is MIC<16/64, minocycline or fosfomycin is susceptible.
• If MIC to meropenem is <16064; and KPC identified-dual carbapenem therapy.

Emerging carbapenem resistance GNBs: Stenotrophomonas and Elizabethkingia

• Polymyxins and carbapenems: inherently resistant.
• Susceptible to levoflox, septran and minocycline.
• Local antibiogram to be considered to determine if we have to cover for this in empiric therapy.