Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
ESBL and carbapenemase-producing Gram-negative infection
Essential points for quick revision.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Sepsis with resistant Gram-negative risk
Shock or organ dysfunction in a patient with previous ESBL or CPE, overseas healthcare, recent broad antibiotics or a colonised device may receive inactive standard empirical therapy.
Action: Use ABCDE and sepsis care, obtain blood, urine and source cultures immediately without delaying treatment, alert microbiology and IPC, and start a locally approved regimen active against the patient's prior organisms and resistance mechanism.
Synopsis
Distinguish resistant Enterobacterales carriage from infection, obtain high-quality cultures before treatment, map the resistance mechanism and infection site, choose active narrow therapy with microbiology ownership, and prevent healthcare transmission.
Extended-spectrum beta-lactamases hydrolyse most penicillins and third-generation cephalosporins but usually leave carbapenems active; co-resistance to quinolones and co-trimoxazole is common.
Carbapenemase-producing Enterobacterales carry enzymes such as KPC, OXA-48-like, NDM, VIM or IMP; the enzyme class predicts which newer beta-lactam combination can work.
Colonisation of the bowel, urine around a catheter or a chronic wound does not itself require antibiotics; treat an attributable clinical infection, not the resistance result.
Key red flags
Shock, rising lactate, altered consciousness, oliguria or respiratory failure requires immediate broad active intravenous therapy and source control.
Urinary infection
Dysuria and frequency suggest lower UTI, while fever, loin pain, vomiting or sepsis indicates upper-tract or bloodstream involvement requiring systemic exposure.
Investigation priorities
01
First-line blood and source culturesFirst stepFirst line
Identify the current pathogen and susceptibility from blood, urine, deep tissue, bile, drainage or another true infection focus.
Management branches
CULTURE FIRSTIdentify infection and resistance history
A patient with ESBL or CPE risk develops local symptoms, fever, sepsis or a new positive culture.
Perform ABCDE and obtain blood plus high-quality source cultures before antimicrobials if collection is immediate; do not delay resuscitation or an active first dose in shock.
Retrieve previous species, MICs and carbapenemase results, overseas or outbreak healthcare and recent antibiotics and devices.
Key medicines
MeropenemGive 1 g intravenously every eight hours for severe ESBL infection, using an extended infusion and higher site-specific dose only under the local protocol, with renal adjustment.
ErtapenemGive 1 g intravenously every 24 hours for selected stable susceptible ESBL infection after source control, with renal adjustment.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.