TABLE 6.

Criteria for appropriate use of carbapenems

Type of therapy	Descriptiona
Targeted	For treatment of serious cephalosporin-resistant e.g., ESBL-resistant Gram-negative infections
	For second-line treatment of Gram-positive/Gram-negative infections in serious penicillin or cephalosporin allergy (e.g., extensive rash, angioedema, or anaphylactic reactions)
	Ertapenem should only be used as targeted therapy or as deescalation therapy from other broad-spectrum carbapenems when the following criteria are met: (i) for treatment of ertapenem-susceptible Gram-negative bacteria resistant to other beta-lactam antibiotics or/and fluoroquinolones (and not Pseudomonas spp.), and/or (ii) if patient is amenable to outpatient i.m./i.v. ertapenem antimicrobial therapy
Empiric	Empirical first-line therapy in severe/overwhelming sepsis (especially multiorgan dysfunction) requiring ventilatory and/or inotropic support for (i) severely ill neutropenic hemato-oncologic patients, (ii) severely ill patients with pneumonia/ARDS who may have suspected infection with Burkholderia pseudomallei, (iii) severely ill patients with intra-abdominal sepsis, and (iv) severely ill neonatal patients in intensive care unit with signs of worsening sepsis
	Empirical second- or third-line therapy for febrile neutropenic patients with strong evidence of cephalosporin-resistant Gram-negative infection: (i) known colonization with cephalosporin-resistant (e.g., ESBL) Gram-negative organisms (e.g., hemato-oncologic patients with mucositis or typhlitis) and (ii) blood culture positive for Gram-negative bacteria before final identification and susceptibility testing
Prophylactic (to discuss with ASP physician/pharmacist for prophylactic use)	Prophylaxis for major surgical procedures in a patient with serious penicillin and cephalosporin allergy and prophylaxis for major surgical procedures in patients with preexisting infections with cephalosporin-resistant Gram-negative bacteria at the site of surgery

^aESBL, extended-spectrum beta-lactamase; i.m., intramuscular; i.v., intravenous; ARDS, acute respiratory distress syndrome.