Indian consensus on the management of carbapenem-resistant enterobacterales infection in critically ill patients II (ICONIC II)

ABSTRACT

Introduction

The rising challenge of carbapenem-resistant Enterobacterales (CRE) infections in Indian healthcare settings calls for clear clinical guidance on the management of these infections. The Indian consensus on the management of CRE infection in critically ill patients (ICONIC-II) is a follow-up of the ICONIC-I study, which was undertaken in 2019.

Areas Covered

A modified Delphi method was used to build expert consensus on CRE management in India, involving online surveys, face-to – face expert meetings, and a literature review. A panel of 12 experts was formed to develop potential clinical consensus statements (CCSs), which were rated through two survey rounds. The CCSs were finalized in a final face-to – face discussion. The finalized CCSs were categorized as consensus, near consensus, and no consensus.

Expert Opinion

The outcomes included 46 CCSs (consensus: 40; near consensus: 3; and no consensus: 3). The expert panel discussed and achieved consensus on various strategies for managing CRE infections, emphasizing the significance of existing and emerging resistance mechanisms, prompt and tailored empiric therapy, and use of combination therapies. The consensus statements based on the collective expertise of the panel can potentially assist clinicians in the management of CRE infections that lack high-level evidence.

KEYWORDS:

• Carbapenem resistance
• Ceftazidime-avibactam
• consensus statements
• CRE
• critical illness
• drug resistance
• Enterobacteriaceae infections
• India

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Correction

Article highlights

• Carbapenem resistance in ICU settings has risen steadily over the past decade, with CRKP and CREco being predominant, accounting for over 90% of all CRE strains.

• Common resistance mechanisms in India include NDM and OXA-48, while PBP-3 inserts significantly impact antibiotic efficacy, particularly against carbapenems.

• Diagnostic challenges persist due to the complexity of carbapenemase detection, but rapid tests and molecular assays aid in timely diagnosis, requiring a combined approach for accuracy.

• Empirical therapy for CRE infections relies on the CAZ – AVI + ATM combination, especially in critically ill patients, while polymyxins remain crucial for CNS infections.

• Active surveillance for CRE colonization is vital for guiding empirical therapy decisions and infection control measures, particularly in high-risk patients.

• CAZ – AVI monotherapy is recommended for OXA-48–like CP CRE infections, but dosage adjustments are critical, especially in patients with renal impairment.

• Ongoing surveillance, optimized dosing strategies, and further research into novel therapies are essential to combat the evolving landscape of CRE infections in critical care settings.

Declaration of interest

RS has received payment or honoraria for lectures, presentations and participated in advisory board of Pfizer, MSD, Mylan, Cipla, Glenmark and Hoffmann la Roche. AH has served on the advisory of Pfizer, Glenmark, Fusion, Cipla. ST has served on the advisory of Cipla, Pfizer, MSD. RKS has served on the advisory of Cipla, Pfizer, MSD, Glenmark, Fusion, Sanofi, Astra Zeneca. VN has served on the advisory of Cipla, Pfizer, Astellas, Glenmark, Fusion, Mylan. CR is on a scientific advisory board of Pfizer, Sanofi, Biomerieux and has speaker agreements with Sanofi, Becton Dickinson, Cipla, Glenmark, Novartis and Cepheid. SS has served on the advisory of Mylan, Pfizer, Sanofi. AP, SB, SP, HB are employees of Glenmark Pharmaceuticals Ltd and declare no conflict of interest. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. The rest of the authors declare no conflict of interest.

Correction Statement

This article was originally published with errors, which have now been corrected in the online version. Please see Correction (http://dx.doi.org/10.1080/14787210.2024.2370086)

Additional information

Funding

This work was supported by Glenmark Pharmaceuticals Ltd.