1. The document defines uncomplicated gram-negative rod (GNR) bacteremia and reviews current guidelines from IDSA on treatment duration and use of step-down oral therapy.
2. Uncomplicated GNR bacteremia is defined as secondary to a site of infection with source control and clinical improvement within 72 hours. Guidelines recommend 7 days of effective therapy for uncomplicated cases.
3. For uncomplicated GNR bacteremia, guidelines support transitioning to oral step-down therapy with fluoroquinolones or TMP/SMX after 3-5 days of IV therapy if the patient has a functional GI tract and oral agents are susceptible.
1. The document defines uncomplicated gram-negative rod (GNR) bacteremia and reviews current guidelines from IDSA on treatment duration and use of step-down oral therapy.
2. Uncomplicated GNR bacteremia is defined as secondary to a site of infection with source control and clinical improvement within 72 hours. Guidelines recommend 7 days of effective therapy for uncomplicated cases.
3. For uncomplicated GNR bacteremia, guidelines support transitioning to oral step-down therapy with fluoroquinolones or TMP/SMX after 3-5 days of IV therapy if the patient has a functional GI tract and oral agents are susceptible.
1. The document defines uncomplicated gram-negative rod (GNR) bacteremia and reviews current guidelines from IDSA on treatment duration and use of step-down oral therapy.
2. Uncomplicated GNR bacteremia is defined as secondary to a site of infection with source control and clinical improvement within 72 hours. Guidelines recommend 7 days of effective therapy for uncomplicated cases.
3. For uncomplicated GNR bacteremia, guidelines support transitioning to oral step-down therapy with fluoroquinolones or TMP/SMX after 3-5 days of IV therapy if the patient has a functional GI tract and oral agents are susceptible.
1. The document defines uncomplicated gram-negative rod (GNR) bacteremia and reviews current guidelines from IDSA on treatment duration and use of step-down oral therapy.
2. Uncomplicated GNR bacteremia is defined as secondary to a site of infection with source control and clinical improvement within 72 hours. Guidelines recommend 7 days of effective therapy for uncomplicated cases.
3. For uncomplicated GNR bacteremia, guidelines support transitioning to oral step-down therapy with fluoroquinolones or TMP/SMX after 3-5 days of IV therapy if the patient has a functional GI tract and oral agents are susceptible.
1. Define uncomplicated gram-negative rod (GNR) bacteremia
2. Review current guidelines on GNR bacteremia
3. Draw conclusions based on findings from primary literature regarding treatment
duration and step-down therapy for GNR bacteremia
2 Background
3 Clinical Significance
Incidence • 3.77 episodes/10,000 person-years for community-acquired, community onset • 2.60 episodes/10,000 person-years for healthcare-associated, community onset • 4.53 episodes/10,000 patient-days for hospital-onset
Mortality • 10 to 40%
Hospital Burden • Previous guidelines recommended an appropriate IV antibiotic course for 7-14 days
Centers for Disease Control and Prevention. Antimicrobial Nonsusceptibility of Gram-Negative Bloodstream Isolates 2003–2013. Gikas A, et al. Infection 1998. Kang CI, et al. Antimicrob Agents Chemother 2005. 4 Defining GNR Bacteremia
Bacteremia: bacterial infection of the bloodstream
Gram-Negative Bacilli (Rods)*
Citrobacter spp. Klebsiella spp.
Enterobacter spp. Proteus spp. Escherichia coli Providencia spp. Morganella morganii Acinetobacter baumannii Serratia spp. Pseudomonas aeruginosa Shigella spp. Stenotrophomonas maltophilia *Not an all inclusive list
5 Previous Guidance From IDSA
6 2009 IDSA Intravascular Catheter-Related Infection Guidelines Choice of Antimicrobial Agent • Based on local antimicrobial susceptibility data and severity of disease Duration of Therapy • 7-14 days • Consider longer duration of therapy in those with persistent bacteremia or severe sepsis despite systemic and antibiotic lock therapy
• Vancomycin-resistant Enterococcus (VRE): may be treated with oral linezolid • Candida spp: may be treated with oral fluconazole • Consider switching to oral therapy once blood cultures are negative and signs of sepsis have resolved OR if patient is improving and source control has been achieved
NOTE: The definition of “uncomplicated gram-negative bloodstream infections” is NOT limited to
enterobacterales. Pseudomonas aeruginosa, other nonfermenting gram-negative organisms (e.g. Acinetobacter baumannii or Stenotrophomonas maltophilia), and multi-drug resistant organisms are encompassed in this definition.
Duration of Therapy • Uncomplicated GN-BSI: 7 days of effective therapy • Other: 10-14 days of effective therapy IV to PO • Uncomplicated GN-BSI may be treated with oral therapy if... • The patient demonstrates clinical improvement on IV therapy • The patient has a functional gastrointestinal tract • Susceptibility testing confirms oral options are appropriate • No defined duration of IV therapy prior to conversion Heil EL, et al. OFID 2021. 12 2021 IDSA Gram-Negative Bloodstream Infections Consensus Statements
• Repeat blood cultures are not recommended in the vast majority of GN-BSI cases • May consider repeat blood cultures if… • Lacking appropriate clinical response within 72 hours • Concern for an endovascular infection or endocarditis • No source control
Heil EL, et al. OFID 2021.
15 Further Reading
16 Key Takeaways From Primary Literature Review 1. Most data regarding step-down from IV to PO therapy for GN-BSI involved infections where the primary source was UTI or gastrointestinal with the most common isolates being E. Coli and Klebsiella.
2. Most studies support a shorter duration of therapy (7-10 days) rather than a longer duration (>10 days).
3. Most studies support the transition from IV to PO therapy after 3-5 days of effective IV therapy.
4. Ciprofloxacin, levofloxacin, and TMP/SMX are the most commonly studied oral agents.
