Expanding Oral Carbapenem Use: Guardrails and Real-World Evidence Needs

In "Expanding Oral Carbapenem Use: Guardrails and Real-World Evidence Needs," our experts look past the approved indication to where this therapy is already headed next.

Dr. Gupta asks Dr. Kaye where else in the outpatient setting an oral carbapenem could reduce hospitalizations. Dr. Kaye anticipates off-label use for uncomplicated cystitis, though he notes existing non-systemic oral options already serve much of that space with less microbiome disruption. He also anticipates use for infections outside the urinary tract, including respiratory and bloodstream infections, where carbapenems are already used intravenously. He expects broader use to spread from hospitals into community settings over time. He cautions, though, that outpatient stewardship remains a vast, difficult space to monitor, especially for a genuinely novel oral carbapenem. The field will need to use it carefully to preserve its effectiveness for years to come. Dr. Gupta then asks Dr. Nelson what real-world evidence would help establish appropriate guardrails. Dr. Nelson highlights the trial's fully oral design as one of its most valuable features, since definitive data on all-oral treatment for complicated UTI has historically been lacking. Both major recent guidelines acknowledge that same evidence gap. He finds reassurance in evidence from deeper infections like osteomyelitis and endocarditis showing oral therapy can match intravenous efficacy when pharmacokinetic targets are met. He suggests urinary tract infections, an even more favorable infection source, should perform at least as well. Still, Dr. Nelson wants future real-world studies to directly compare fully oral regimens against the traditional short intravenous course followed by an oral switch. That data, he argues, could finally challenge the default assumption that these patients need hospital admission at all. It could show that even the shortened hospitalization was never truly necessary.

In "Susceptibility Testing and the Future of Complicated UTI Care," the panel closes the series with a look five years down the road.