Approaches to challenging cases with limited therapies

EP: 1.Pathogen prevalence, emerging threats, and regional resistance patterns

EP: 2.The role of rapid diagnostics and collaboration in antibiotic stewardship

EP: 3.Guiding empirical therapy through patient risk assessment

EP: 4.Aligning treatment with risk factors, patient profiles, and MBL status

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EP: 5.Approaches to challenging cases with limited therapies

EP: 6.Strategies for addressing MBL infections with targeted antibiotic combination therapy, and clinical insights from the REVISIT study

EP: 7.Evidence and trials informing treatment of resistant Gram-negative infections

EP: 8.Integration of susceptibility testing and local surveillance to inform antibiotic use

EP: 9.Challenges and opportunities in implementing new antibiotics with QIDP and Fast Track status

EP: 10.Guiding appropriate use of colistin and polymyxins

EP: 11.Optimizing formulary decisions and new drug approval through data and team collaboration

EP: 12.Approaches to equitable and responsible antibiotic management

Managing infections caused by highly resistant organisms presents ongoing challenges, particularly in settings where access to novel diagnostics and therapeutics is limited. One case involved an older patient with significant comorbidities who developed a bloodstream infection caused by carbapenem-resistant Klebsiella pneumoniae. Despite identifying the resistance mechanism as Klebsiella pneumoniae carbapenemase through molecular testing, treatment options were severely constrained due to the hospital’s limited formulary. The available agents—colistin and tigecycline—posed toxicity and efficacy concerns, particularly in the context of the patient’s renal impairment. Unfortunately, the patient succumbed to septic shock, underscoring the life-threatening consequences of limited drug access and delayed optimal therapy.

In contrast, another scenario highlighted a more favorable outcome, where a patient with a previously identified metallo-β-lactamase (MBL)–producing Klebsiella later presented with sepsis. Due to prior documentation, the care team initiated therapy with a novel β-lactam/β-lactamase inhibitor that the organism was likely susceptible to. Although treatment was successful, discharge planning posed new logistical hurdles. The patient’s home infusion required prolonged and complex administration involving multiple 1-g vials infused back-to-back over gravity, resulting in extended infusion times. Stability issues of the drug outside hospital settings further complicated care, revealing how even when drugs are available, practical implementation can be a barrier—especially in outpatient or resource-limited environments.

Another complex case involved an outbreak of MBL-producing Pseudomonas in a burn intensive care unit. In these instances, the usual novel agents used for MBLs in Enterobacterales were ineffective, and the only option was colistin, which carries significant toxicity and uncertain efficacy. Despite best efforts, patients often did not survive. These scenarios emphasize the urgent need for new antimicrobial agents with broader activity profiles, improved drug delivery systems, and more widespread access—especially in high-risk and under-resourced clinical settings.