IDSA 2026 Guidance Makes Sulbactam-Durlobactam the Priority for CRAB Infections

The Infectious Diseases Society of America (IDSA) 2026 guidance on antimicrobial-resistant gram-negative infections, published July 30, 2026, prioritizes sulbactam-durlobactam (Xacduro; Innoviva Specialty Therapeutics) for invasive carbapenem-resistant Acinetobacter baumannii (CRAB) infections.¹ The preferred regimen pairs sulbactam-durlobactam with a carbapenem, and alternative options should serve only as bridge therapy until sulbactam-durlobactam is available.¹ For isolates resistant to sulbactam-durlobactam, the guidance suggests 2 non-sulbactam agents or the addition of sulbactam-durlobactam to cefiderocol.¹

The update strengthens language from the 2024 version, which also listed sulbactam-durlobactam plus a carbapenem as the preferred CRAB regimen.¹ Sulbactam-durlobactam is approved in the United States for adults 18 years and older with hospital-acquired or ventilator-associated bacterial pneumonia caused by susceptible Acinetobacter baumannii-calcoaceticus complex isolates.³

The phase 3 ATTACK trial supporting approval randomly assigned 181 patients to sulbactam-durlobactam or colistin, each given with background imipenem-cilastatin.² In the CRAB population, 28-day all-cause mortality was 19% (12/63) with sulbactam-durlobactam vs 32% (20/62) with colistin, meeting noninferiority criteria.² Nephrotoxicity occurred in 13% (12/91) of sulbactam-durlobactam recipients vs 38% (32/85) of colistin recipients (P < .001).²

The 2026 language moves sulbactam-durlobactam from a preferred option to the default target for invasive CRAB, with other regimens framed as temporary.¹ For clinicians, the change places formulary access and rapid availability of sulbactam-durlobactam at the center of CRAB management.¹

David Altarac, MD, chief medical officer at Innoviva Specialty Therapeutics, which markets sulbactam-durlobactam in the United States, spoke with Contagion at IDWeek 2026 in Washington, DC, about the guidance update and its implications for CRAB treatment decisions.³

Contagion: The 2026 IDSA guidance makes sulbactam-durlobactam the priority for invasive CRAB infections. What are the key takeaways for clinicians?

David Altarac, MD: Sulbactam-durlobactam, or Xacduro, was approved in the US in 2023 for the treatment of hospital-acquired and ventilator-associated pneumonias due to Acinetobacter infections in adults. Carbapenem-resistant Acinetobacter infections have historically been very difficult to treat, with limited treatment options.

Shortly after approval, IDSA issued its guidance and identified Xacduro, along with a carbapenem, as a preferred treatment for carbapenem-resistant Acinetobacter. The recently updated guidance again identifies Xacduro as a first-line agent, in combination with a carbapenem, as the preferred treatment option for invasive CRAB infections. This represents a shift from relying on limited options toward a therapy designed to address the organism’s resistance mechanism, and is an important advancement in how we make treatment decisions.

Editor’s Note: This transcript has been edited for grammar and clarity using artificial intelligence tools.

Check out the first episode of the ID Week interview with Altarac:
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REFERENCES:

1. Infectious Diseases Society of America. IDSA 2026 guidance on the treatment of antimicrobial-resistant gram-negative infections. Published July 30, 2026. Accessed October 26, 2026. https://www.idsociety.org/practice-guideline/amr-guidance/

2. Kaye KS, Shorr AF, Wunderink RG, et al. Efficacy and safety of sulbactam-durlobactam versus colistin for the treatment of patients with serious infections caused by Acinetobacter baumannii-calcoaceticus complex: a multicentre, randomised, active-controlled, phase 3, non-inferiority clinical trial (ATTACK). Lancet Infect Dis. 2023;23(9):1072-1084. doi:10.1016/S1473-3099(23)00184-6

3. Innoviva Specialty Therapeutics. Innoviva Specialty Therapeutics announces distribution and licensing agreement with Dr. Reddy’s for XACDURO in select international markets. Published June 16, 2026. Accessed October 26, 2026. https://investor.inva.com/node/21156/pdf