Note: Doses are expressed as the combined amount of imipenem, cilastatin, and relebactam. Not recommended for routine empiric use. Reserve for patients with or at risk for extensively drug-resistant pathogens (nonsusceptible to ≥1 agent in all but 2 or fewer antimicrobial classes) (eg, carbapenem-resistant Enterobacterales) (IDSA [Tamma 2020]; Magiorakos 2012; Quale 2021; Yahav 2020).
Intra-abdominal infection, complicated : IV: 1.25 g every 6 hours. Total duration of therapy is 4 to 7 days following adequate source control (SIS [Mazuski 2017]; SIS/IDSA [Solomkin 2010]); for infections managed without surgical or percutaneous intervention, a longer duration may be necessary (Barshak 2019; Pemberton 2019).
Pneumonia, hospital acquired or ventilator associated: IV: 1.25 g every 6 hours. Duration of therapy varies based on disease severity and response to therapy; treatment is typically given for 7 days, but a longer course may be required for severe or complicated infection (IDSA/ATS [Kalil 2016]).
Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms):
IV: 1.25 g every 6 hours. Switch to an appropriate oral regimen once symptoms improve, if culture and susceptibility results allow. Total duration of therapy ranges from 5 to 14 days and depends on clinical response and the antimicrobial chosen to complete the regimen (Hooton 2021; IDSA [Tamma 2020]; Motsch 2020; Sims 2017).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Note: Estimation of renal function for the purpose of dosage adjustment should be done using the Cockcroft-Gault formula. Doses are expressed as the combined amount of imipenem, cilastatin, and relebactam.
CrCl ≥90 mL/minute: No dosage adjustment necessary.
CrCl 60 to 89 mL/minute: 1 g every 6 hours.
CrCl 30 to 59 mL/minute: 750 mg every 6 hours.
CrCl 15 to 29 mL/minute: 500 mg every 6 hours.
CrCl <15 mL/minute: Do not administer unless hemodialysis is instituted within 48 hours.
End-stage renal disease on hemodialysis: 500 mg every 6 hours; administer after hemodialysis and at intervals timed from the end of that hemodialysis session.
Peritoneal dialysis: Use is not recommended (inadequate data).
There are no dosage adjustments provided in the manufacturer's labeling; however, hepatic impairment is not likely to have any effect on exposure.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous [preservative free]:
Recarbrio: Imipenem 500 mg, cilastatin 500 mg, and relebactam 250 mg (1 ea)
No
IV: Infuse over 30 minutes.
Intra-abdominal infection, complicated: Treatment of complicated intra-abdominal infections in patients ≥18 years of age with limited or no alternative options caused by the following susceptible gram-negative microorganisms: Bacteroides cacace, Bacteroides fragilis, Bacteroides ovatus, Bacteroides thetaiotaomicron, Bacteroides uniformis, Bacteroides vulgatus, Bifidobacterium stercoris, Citrobacter freundii, Enterobacter cloacae, Escherichia coli, Fusobacterium nucleatum, Klebsiella aerogenes, Klebsiella oxytoca, Klebsiella pneumoniae, Parabacteroides distasonis, and Pseudomonas aeruginosa.
Pneumonia, hospital acquired or ventilator associated: Treatment of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in patients ≥18 years of age caused by the following susceptible gram-negative microorganisms: Acinetobacter calcoaceticus-baumannii complex, E. cloacae, E. coli, Haemophilus influenzae, K. aerogenes, K. oxytoca, K. pneumoniae, P. aeruginosa, and Serratia marcescens.
Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms): Treatment of complicated urinary tract infections, including pyelonephritis, in patients ≥18 years of age with limited or no alternative options caused by the following susceptible gram-negative microorganisms: E. cloacae, E. coli, K. aerogenes, K. pneumoniae, and P. aeruginosa.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Hematologic & oncologic: Anemia (11%)
Hepatic: Increased serum aspartate aminotransferase (12%)
1% to 10%:
Dermatologic: Skin rash (4%)
Endocrine & metabolic: Hypokalemia (8%), hyponatremia (6%)
Gastrointestinal: Constipation (4%), diarrhea (8%)
Hematologic & oncologic: Thrombocytopenia (<4%)
Hepatic: Increased serum alanine aminotransferase (10%)
Miscellaneous: Fever (4%)
Frequency not defined: Gastrointestinal: Clostridioides difficile associated diarrhea
Severe hypersensitivity (eg, anaphylaxis) to cilastatin, imipenem, relebactam, or any component of the formulation.
Documentation of allergenic cross-reactivity for carbapenems, penicillins, and cephalosporins is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.
Concerns related to adverse effects:
• CNS effects: Carbapenems have been associated with CNS adverse effects, including confusional states and seizures (myoclonic); use caution with CNS disorders (eg, brain lesions, history of seizures) and adjust dose in renal impairment to avoid drug accumulation. Drug accumulation may increase seizure risk.
• Hypersensitivity reactions: Serious hypersensitivity/anaphylactic reactions, some fatal, have been reported with beta-lactams. Carefully inquire about previous hypersensitivity reactions to penicillins, carbapenems, cephalosporins, other beta-lactams, and other allergens. Discontinue treatment and institute supportive care if a hypersensitivity reaction occurs.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including Clostridioides difficile-associated diarrhea (CDAD); CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment required. Increased seizure risk has been reported in patients with significant renal dysfunction. Do not use in patients with CrCl ≤15 mL/minute unless hemodialysis is instituted within 48 hours.
Refer to individual components.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification
BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy
Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination
CycloSPORINE (Systemic): Imipenem may enhance the neurotoxic effect of CycloSPORINE (Systemic). Risk C: Monitor therapy
Ganciclovir-Valganciclovir: May enhance the adverse/toxic effect of Imipenem. Specifically, the risk of seizures may be increased. Management: Avoid concomitant use of these agents unless the prospective benefits of therapy outweigh the risks. Risk D: Consider therapy modification
Immune Checkpoint Inhibitors: Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors. Risk C: Monitor therapy
Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy
Probenecid: May increase the serum concentration of Imipenem. Risk C: Monitor therapy
Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification
Valproate Products: Carbapenems may decrease the serum concentration of Valproate Products. Management: Concurrent use of carbapenem antibiotics with valproic acid is generally not recommended. Alternative antimicrobial agents should be considered, but if a concurrent carbapenem is necessary, consider additional anti-seizure medication. Risk D: Consider therapy modification
Imipenem and cilastatin cross the placenta (Cho 1988; Heikkilä 1992). Information specific to relebactam has not been located.
Also refer to the imipenem/cilastatin monograph for additional information.
Imipenem is present in breast milk (Chung 2002; Ito 1988). Excretion of relebactam is not known.
Also refer to the imipenem/cilastatin monograph for additional information.
Periodic renal function tests; signs of hypersensitivity/anaphylaxis.
Imipenem: Binds to PBP 2 and PBP 1B in Enterobacteriaceae and P. aeruginosa and subsequently inhibits penicillin-binding proteins, leading to the disruption of bacterial cell wall synthesis.
Cilastatin: Renal dehydropeptidase inhibitor that limits renal metabolism of imipenem.
Relebactam: Beta-lactamase inhibitor that protects imipenem from degradation by certain serine beta-lactamases (eg, Sulhydryl Variable, Temoneira, Cefotaximase-Munich, E. cloacae P99, Pseudomonas-derived cephalosporinase, and Klebsiella-pneumoniae carbapenemase).
Distribution: Vdss: Imipenem: 24.3 L; cilastatin: 13.8 L; relebactam: 19 L.
Protein binding: Imipenem: ~20%; cilastatin: ~40%; relebactam: ~22%.
Metabolism: Imipenem is metabolized in the kidney by dehydropeptidase I; cilastatin prevents imipenem metabolism by this enzyme. Relebactam is minimally metabolized.
Half-life elimination: Imipenem: 1 hour; relebactam: 1.2 hours.
Excretion: Urine (as unchanged drug: imipenem: ~63%; cilastatin: ~77%; relebactam: >90%).
Altered kidney function: AUC is increased in patients with CrCl 15 to 89 mL/minute (imipenem: 1.1 to 2.6-fold; cilastatin: 1.2 to 5.5-fold; relebactam: 1.2 to 4.7-fold).
Anti-infective considerations:
Parameters associated with efficacy:
Imipenem and cilastatin (in combination with relebactam):
Interrelationship between imipenem and cilastatin exposure, relebactam exposure, minimum inhibitory concentration (MIC), and efficacy is not fully elucidated; efficacy is time dependent (see Imipenem and Cilastatin monograph), but MIC changes with changing relebactam concentrations (MICdynamic). Maximal efficacy was achieved at fT > MICdynamic >40% to 50% (Bhagunde 2012; Wu 2018).
Relebactam (in combination with imipenem and cilastatin):
AUC, associated with free 24-hour AUC (fAUC24) of relebactam to imipenem and cilastatin-relebactam MIC ratio.
Gram negative organisms (including P. aeruginosa): Goal: 2.7 (bacteriostasis), 4.7 (1-log kill), 7.5 (2-log kill) (Bhagunde 2019a; Bhagunde 2019b; Mavridou 2015).
Postantibiotic effect: Imipenem and cilastatin: See Imipenem and Cilastatin monograph.
Parameters associated with toxicity: Imipenem and cilastatin: See Imipenem and Cilastatin monograph.
Solution (reconstituted) (Recarbrio Intravenous)
1.25 g (per each): $340.56
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