Note: Generally reserved for patients with pathogens that are resistant to other antibiotics, such as extended-spectrum beta-lactamase (ESBL)-producing organisms (Ref). Unlike other carbapenems (eg, doripenem, imipenem, meropenem), ertapenem lacks activity against Pseudomonas aeruginosa.
Bite wound infection, treatment (animal or human bite) (alternative agent) (off-label use): IV: 1 g once daily. Duration of treatment for established infection (which may include oral step-down therapy) is typically 5 to 14 days and varies based on patient-specific factors, including clinical response (Ref).
Bloodstream infection (pathogen-directed therapy for susceptible gram-negative organisms) (off-label use): IV: 1 g once daily (Ref). Duration is 7 to 14 days, depending on source and extent of infection, as well as clinical response; a 7-day duration is recommended for patients with uncomplicated Enterobacteriaceae bacteremia who respond appropriately to antibiotic therapy (Ref).
Diabetic foot infection, moderate to severe: IM, IV: 1 g once daily. Duration (which may include oral step-down therapy) is usually 2 to 4 weeks in the absence of osteomyelitis but varies based on patient-specific factors, including clinical response (Ref).
Intra-abdominal infection, mild to moderate, community-acquired in patients without risk factors for resistance or treatment failure (alternative agent):
Note: Reserve for patients unable to take first-line agents (eg, piperacillin/tazobactam) (Ref).
Cholecystitis, acute: IV: 1 g once daily; continue for 1 day after gallbladder removal or until clinical resolution in patients managed nonoperatively (Ref).
Other intra-abdominal infections (eg, perforated appendix, appendiceal abscess, cholangitis, diverticulitis): IM, IV: 1 g once daily. Total duration of therapy (which may include transition to oral antibiotics) is 4 to 5 days following adequate source control (Ref); for diverticulitis or uncomplicated appendicitis managed without intervention, duration is 10 to 14 days (Ref).
Osteomyelitis and/or discitis (pathogen-directed therapy for susceptible gram-negative organisms) (off-label use): IV: 1 g once daily, generally for ≥6 weeks depending on patient-specific factors, such as extent of infection, debridement, and clinical response. Shorter courses are appropriate if the affected bone is completely resected (eg, by amputation) (Ref).
Pelvic infection, acute (eg, postpartum and postsurgical gynecologic infections) (alternative agent): IM, IV: 1 g once daily; duration of therapy varies based on type of infection.
Pneumonia (alternative agent):
Community-acquired pneumonia, empiric therapy (inpatients without risk factors for Pseudomonas aeruginosa ): IM, IV: 1 g once daily as part of an appropriate combination regimen. Duration (which may include oral step-down therapy) is for a minimum of 5 days; patients should be clinically stable with normal vital signs before therapy is discontinued (Ref).
Hospital-acquired pneumonia or ventilator-associated pneumonia (pathogen-directed therapy for extended-spectrum beta-lactamase-producing organisms) (off-label use): IV: 1 g once daily (Ref). Duration of therapy varies based on disease severity and response to therapy; treatment is typically given for 7 days (Ref).
Prosthetic joint infection (pathogen-directed therapy for susceptible gram-negative organisms) (off-label use): IV: 1 g every 24 hours; duration varies, but is generally 4 to 6 weeks for patients who undergo resection arthroplasty (Ref).
Skin and soft tissue infection, moderate to severe:
Note: For patients with select surgical site infections (intestinal, GU tract), necrotizing infections, or patients with or at risk for pathogens resistant to other agents (Ref).
IV: 1 g once daily; often used as part of an appropriate combination regimen. Usual duration (including oral step-down therapy) is 5 to 14 days based on severity and clinical response; for necrotizing infections, continue until further debridement is not necessary and the patient has improved clinically and is afebrile for 48 to 72 hours (Ref).
Surgical prophylaxis (colorectal surgery) (alternative agent): IV: 1 g within 60 minutes prior to surgical incision (Ref). Note: Postoperative prophylaxis is not recommended in clean and clean-contaminated surgeries (Ref). Some experts recommend against using ertapenem for surgical prophylaxis out of concern for inducing resistance (Ref).
Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms) (alternative agent):
Inpatients: IV, IM: 1 g once daily. 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 (Ref).
Outpatients: IV, IM: 1 g as a single dose, followed by 5 to 14 days of appropriate oral therapy. Note: For patients who are systemically ill, at risk for more severe illness, or at risk for multidrug-resistant infection, some experts continue daily parenteral therapy pending culture and susceptibility testing results (Ref).
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function: IM, IV:
CrCl >30 mL/minute/1.73 m2: No dosage adjustment necessary.
CrCl ≤30 mL/minute/1.73 m2: 500 mg once daily.
Hemodialysis, intermittent (thrice weekly):
Daily dosing: IM, IV: 500 mg once daily. When scheduled dose falls on a hemodialysis day, administer at least 6 hours prior to hemodialysis or wait until after hemodialysis; however, if the dose is given within 6 hours prior to hemodialysis, a supplementary dose of 150 mg is required following hemodialysis.
Three times weekly (post hemodialysis) dosing: IM, IV: 500 mg or 1 g 3 times weekly after hemodialysis on hemodialysis days (Ref).
Note: Consider patient-specific factors such as body weight, infection severity, and residual kidney function when deciding between doses (Ref).
Peritoneal dialysis: IM, IV: 500 mg once daily (Ref).
CRRT: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations were developed through Monte Carlo simulation only and based on high-flux dialyzers and effluent flow rates of 20 to 25 mL/kg/hour (or ~1,500 to 3,000 mL/hour) unless otherwise noted. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection), organism minimum inhibitory concentration (MIC), and residual kidney function. Close monitoring of response and adverse reactions (eg, neurotoxicity) due to drug accumulation is important.
IM, IV: 1 g once daily (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations are based on daily treatments with 4 to 5 L/hour (Ref) or 10 L/hour (Burkhardt 2009) of dialysate/ultrafiltrate flow rate for each 8- to 10-hour session. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection), organism MIC, and residual kidney function. Close monitoring of response and adverse reactions (eg, neurotoxicity) due to drug accumulation is important.
IM, IV: 500 mg initially, then 500 mg post each PIRRT session or 1 g once daily (Ref).
Adjustments cannot be recommended (lack of experience and research in this patient population).
(For additional information see "Ertapenem: Pediatric drug information")
General dosing, susceptible infection (Ref): Due to limited clinical data, ertapenem is usually reserved for extended-spectrum beta-lactamase (ESBL) infections with urinary sources or soft tissue infections when adequate source control has been achieved (Ref). Unlike other carbapenems (eg, doripenem, imipenem, meropenem), ertapenem lacks activity against Pseudomonas aeruginosa.
Infants and Children: IM, IV: 15 mg/kg/dose twice daily; maximum dose: 500 mg/dose.
Adolescents: IM, IV: 1,000 mg once daily.
Intra-abdominal infection, complicated: Note: Guidelines recommend a treatment duration of 4 to 7 days (provided source controlled) for community-acquired, mild to moderate infections(Ref); manufacturer labeling suggests a duration of 5 to 14 days; however, longer durations (>7 days) have not been associated with improved outcomes (Ref).
Infants ≥3 months and Children: IM, IV: 15 mg/kg/dose twice daily; maximum dose: 500 mg/dose.
Adolescents: IM, IV: 1,000 mg once daily.
Pelvic infections, acute:
Infants ≥3 months and Children: IM, IV: 15 mg/kg/dose twice daily for 3 to 10 days based on severity of infection; maximum dose: 500 mg/dose.
Adolescents: IM, IV: 1,000 mg once daily for 3 to 10 days based on severity of infection.
Pneumonia, community-acquired: Note: Guidelines suggest a usual duration of therapy of 10 days (including both parental and possible switch to appropriate oral step-down therapy); however, longer duration may be necessary for some organisms and/or complicated infections (Ref).
Infants ≥3 months and Children: IM, IV: 15 mg/kg/dose twice daily for 10 to 14 days; maximum dose: 500 mg/dose.
Adolescents: IM, IV: 1,000 mg once daily for 10 to 14 days.
Skin and skin structure infections, complicated or necrotizing: Note: For complicated infection, continue therapy for 7 to 14 days. For necrotizing infection, use in combination with an agent effective against MRSA (eg, vancomycin, linezolid, daptomycin) for empiric therapy of polymicrobial (mixed) infections. Continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (Ref).
Infants ≥3 months and Children: IM, IV: 15 mg/kg/dose twice daily; maximum dose: 500 mg/dose.
Adolescents: IM, IV: 1,000 mg once daily.
Surgical prophylaxis: Limited data available: Children and Adolescents: IV: 15 mg/kg within 60 minutes prior to surgical incision; maximum dose: 1,000 mg/dose (Ref).
Urinary tract infections (including pyelonephritis): Note: Duration includes possible switch to appropriate oral therapy after at least 3 days of parenteral treatment, once clinical improvement demonstrated.
Infants ≥3 months and Children: IM, IV: 15 mg/kg/dose twice daily for 10 to 14 days; maximum dose: 500 mg/dose.
Adolescents: IM, IV: 1,000 mg once daily for 10 to 14 days.
There are no pediatric specific recommendations; based on experience in adult patients, dosage adjustment suggested.
There are no dosage adjustments provided in the manufacturer's labeling; has not be adequately studied.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Injection:
Generic: 1 g (1 ea)
Solution Reconstituted, Injection [preservative free]:
INVanz: 1 g (1 ea)
Generic: 1 g (1 ea)
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Injection:
INVanz: 1 g (3.2 mL)
Generic: 1 g (1 ea)
IM: Avoid injection into a blood vessel. Make sure patient does not have an allergy to lidocaine or another anesthetic of the amide type. Administer by deep IM injection into a large muscle mass (eg, gluteal muscle or lateral part of the thigh). Do not administer IM preparation or drug reconstituted for IM administration intravenously.
IV: Administer as an IV infusion over 30 minutes. May also administer IV push over 5 minutes (Ref).
Parenteral:
IM: Administer by deep IM injection into a large muscle mass such as the gluteus maximus or lateral part of the thigh. Avoid injection into a blood vessel. Must be administered within 1 hour of reconstitution.
Intermittent IV infusion: Infuse over 30 minutes; administration should be completed within 6 hours of reconstitution. Do not coinfuse with other medications. Do not infuse with dextrose-containing solutions.
Intra-abdominal infection, mild to moderate, community-acquired in patients without risk factors for resistance or treatment failure: For the treatment of complicated intra-abdominal infections caused by Clostridium clostridioforme, Escherichia coli, Eubacterium lentum, Peptostreptococcus spp, Bacteroides distasonis, Bacteroides fragilis, Bacteroides ovatus, Bacteroides thetaiotaomicron, or Bacteroides uniformis.
Pelvic infection: For the treatment of acute pelvic infections, including postpartum endomyometritis, septic abortion, and postsurgical gynecologic infections caused by Streptococcus agalactiae, E. coli, B. fragilis, Porphyromonas asaccharolytica, Peptostreptococcus spp, or Prevotella bivia.
Pneumonia, community acquired: For the treatment of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae (penicillin-susceptible isolates only), including cases with concurrent bacteremia; Haemophilus influenzae (beta-lactamase-negative isolates only); or Moraxella catarrhalis.
Skin and skin structure infection, complicated: For the treatment of complicated skin and skin structure infections, including diabetic foot infections without osteomyelitis caused by Staphylococcus aureus (methicillin-susceptible isolates only), S. agalactiae, Streptococcus pyogenes, E. coli, Klebsiella pneumoniae, Proteus mirabilis, B. fragilis, Peptostreptococcus spp, P. asaccharolytica, or P. bivia. Ertapenem has not been studied in diabetic foot infections with concomitant osteomyelitis.
Surgical prophylaxis: For the prophylaxis of surgical site infection in adults following elective colorectal surgery.
Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms): For the treatment of complicated urinary tract infection, including pyelonephritis caused by E. coli, including cases with concurrent bacteremia or K. pneumoniae.
Note: Methicillin-resistant Staphylococcus aureus, Enterococcus spp, Acinetobacter, Pseudomonas aeruginosa, and penicillin-resistant strains of Streptococcus pneumoniae are resistant to ertapenem while most extended-spectrum beta-lactamase (ESBL)-producing bacteria remain sensitive to ertapenem.
Bite wound, treatment (animal or human bite); Bloodstream infection; Osteomyelitis and/or discitis; Pneumonia, hospital acquired or ventilator associated; Prosthetic joint infection
Ertapenem may be confused with doripenem, imipenem, meropenem
INVanz may be confused with AVINza, IV vancomycin
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. As reported in adults, unless otherwise noted.
>10%: Gastrointestinal: Diarrhea (infants, children, adolescents, adults: 9% to 12%)
1% to 10%:
Cardiovascular: Asystole (<2%), atrial fibrillation (<2%), bradycardia (<2%), cardiac arrhythmia (<2%), chest pain (infants, children, adolescents, adults: <2%), edema (≤3%), flushing (<2%), heart failure (<2%), heart murmur(<2%), hypertension (<2%), hypotension (1% to 2%), phlebitis (infants, children, adolescents, adults: <2%), septic shock (<2%), subdural hematoma (<2%), syncope (<2%), tachycardia (<2%), thrombophlebitis (<2%), ventricular tachycardia (<2%)
Dermatologic: Dermatitis (infants, children, adolescents, adults: <2%), desquamation (<2%), diaphoresis (<2%), erythema of skin (<2%), erythematous rash (infants, children, and adolescents: <2%), pruritus (infants, children, adolescents, adults: ≤2%), skin lesion (infants, children, and adolescents: <2%), skin rash (infants, children, adolescents, adults: 2% to 3%), urticaria (<2%)
Endocrine & metabolic: Decreased serum albumin (<2%), decreased serum potassium (<2%), dehydration (<2%), increased serum glucose (<2%), increased serum potassium (<2%), increased serum sodium (<2%), weight loss (<2%)
Gastrointestinal: Abdominal distention (<2%), abdominal pain (infants, children, adolescents, adults: 4% to 5%), acid regurgitation (<2%), anorexia (<2%), cholelithiasis (<2%), Clostridioides difficile-associated diarrhea (<2%), constipation (infants, children, adolescents, adults: 2% to 4%), decreased appetite (infants, children, and adolescents: <2%), duodenitis (<2%), dysgeusia (<2%), dyspepsia (<2%), dysphagia (<2%), esophagitis (<2%), flatulence (<2%), gastritis (<2%), gastrointestinal hemorrhage (<2%), hemorrhoids (<2%), hiccups (<2%), intestinal obstruction (<2%), nausea (infants, children, adolescents: <2%; adults: 6% to 9%), oral candidiasis (infants, children, adolescents, adults: <2%), oral mucosa ulcer (<2%), pancreatitis (<2%), pyloric stenosis (<2%), sore throat (<2%), stomatitis (<2%), upper abdominal pain (infants, children, and adolescents: <2%), vomiting (infants, children, adolescents, adults: 4% to 10%)
Genitourinary: Anuria (<2%), bladder dysfunction (<2%), finding of blood in urine (increased red blood cells: 1% to 3%), genital rash (infants, children, and adolescents: <2%), hematuria (<2%), oliguria (<2%), proteinuria (infants, children, and adolescents: <2%), urinary retention (<2%), vaginitis (1% to 3%), vulvovaginal candidiasis (<2%), vulvovaginal pruritus (<2%), vulvovaginitis (<2%)
Hematologic & oncologic: Decreased hematocrit (3%), decreased hemoglobin (5%), decreased neutrophils (infants, children, adolescents: 6%; adults: <2%), decreased platelet count (<2%), decreased white blood cell count (infants, children, adolescents, adults: <2%), eosinophilia (infants, children, adolescents, adults: ≤2%), hematoma (<2%), leukocyturia (2% to 3%), prolonged partial thromboplastin time (<2%), prolonged prothrombin time (<2%), thrombocythemia (infants, children, adolescents: <2%; adults: 4% to 7%)
Hepatic: Increased serum alanine aminotransferase (infants, children, adolescents, adults: 4% to 9%), increased serum alkaline phosphatase (infants, children, adolescents: <2%; adults: 4% to 7%), increased serum aspartate transaminase (infants, children, adolescents, adults: 4% to 8%), increased serum bilirubin (<2%; including increased direct serum bilirubin or increased indirect serum bilirubin), jaundice (<2%)
Hypersensitivity: Facial edema (<2%)
Infection: Abscess (abdominal: infants, children, and adolescents: <2%), candidiasis (infants, children, adolescents, adults: <2%), herpes simplex infection (infants, children, and adolescents: <2%), septicemia (<2%)
Local: Erythema at injection site (infants, children, and adolescents: 4%), induration at injection site (infants, children, adolescents, adults: <2%), infused vein complication (5% to 7%), infusion-site pain (infants, children, adolescents: 7%), injection-site phlebitis (infants, children, adolescents: <2%), injection-site pruritus (infants, children, and adolescents: <2%), pain at injection site (<2%), swelling at injection site (infants, children, and adolescents: <2%), warm sensation at injection site (infants, children, and adolescents: <2%)
Nervous system: Aggressive behavior (<2%), altered mental status (3% to 5%; including agitation, confusion, decreased mental acuity, delirium, disorientation, drowsiness, stupor), anxiety (<2%), asthenia (<2%), chills (<2%), depression (<2%), dizziness (infants, children, adolescents, adults: ≤2%), fatigue (<2%), headache (infants, children, adolescents, adults: 4% to 7%), hypoesthesia (<2%), hypothermia (infants, children, and adolescents: <2%), insomnia (infants, children, adolescents, adults: ≤3%), malaise (<2%), nervousness (<2%), pain (<2%), paresthesia (<2%), tremor (<2%), vertigo (<2%), voice disorder (<2%)
Neuromuscular & skeletal: Arthralgia (infants, children, and adolescents: <2%), gout (<2%), lower extremity pain (<2%), muscle spasm (<2%)
Renal: Flank pain (<2%), increased blood urea nitrogen (<2%), increased serum creatinine (<2%), renal insufficiency (<2%)
Respiratory: Asthma (<2%), bronchoconstriction (<2%), cough (infants, children, adolescents, adults: ≤4%), dyspnea (1% to 3%), epistaxis (<2%), hemoptysis (<2%), hypoxemia (<2%), nasopharyngitis (infants, children, and adolescents: <2%), pharyngitis (infants, children, adolescents, adults: <2%; including viral), pleural effusion (infants, children, adolescents, adults: <2%), pleuritic chest pain (<2%), rales (<2%), respiratory distress (<2%), rhinitis (infants, children, and adolescents: <2%), rhinorrhea (infants, children, and adolescents: <2%), rhonchi (<2%), upper respiratory tract infection (infants, children, and adolescents: 2%), wheezing (infants, children, and adolescents: <2%)
Miscellaneous: Fever (infants, children, adolescents, adults: 2% to 5%), swelling (infants, children, adolescents, adults: ≤3%), tissue necrosis (<2%)
<1%: Nervous system: Seizure
Postmarking:
Dermatologic: Acute generalized exanthematous pustulosis
Endocrine & metabolic: Hypoglycemia (Kennedy 2019)
Gastrointestinal: Staining of tooth
Hypersensitivity: Anaphylaxis, drug reaction with eosinophilia and systemic symptoms, hypersensitivity angiitis, nonimmune anaphylaxis
Nervous system: Abnormal gait, ataxia, hallucination, impaired consciousness, myasthenia, myoclonus
Neuromuscular & skeletal: Dyskinesia
Known hypersensitivity to any component of this product or to other drugs in the same class or in patients who have demonstrated anaphylactic reactions to beta-lactams; known hypersensitivity to local anesthetics of the amide type due to the use of lidocaine as a diluent (IM use only).
Concerns related to adverse effects:
• Anaphylaxis/hypersensitivity reactions: Serious hypersensitivity reactions, including anaphylaxis, have been reported (some without a history of previous allergic reactions to beta-lactams).
• CNS effects: Carbapenems have been associated with CNS adverse effects, including confusional states and seizures (myoclonic); use caution with CNS disorders (eg, brain lesions and history of seizures) and adjust dose in renal impairment to avoid drug accumulation, which may increase seizure risk.
• Superinfection: Use may result in fungal or bacterial superinfection, including Clostridioides difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment required in patients with moderate to severe renal dysfunction. Increased seizure risk has been reported in patients with renal dysfunction.
Concurrent drug therapy issues:
• Valproic acid and derivatives: Carbapenems, including ertapenem, may decrease the serum concentration of divalproex sodium/valproic acid increasing the risk of breakthrough seizures. Concurrent use of carbapenem antibiotics with divalproex sodium/valproic acid is generally not recommended. Alternative antimicrobial agents should be considered, but if a concurrent carbapenem is necessary, consider additional antiseizure medication.
Special populations:
• Older adult: Lower doses (based upon renal function) are often required in the elderly.
Other warnings/precautions:
• IM administration: Doses for IM administration are mixed with lidocaine; consult Lidocaine (Systemic) information for associated Warnings/Precautions.
Substrate of OAT1/3
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
Fexinidazole: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Management: Avoid use of fexinidazole with OAT1/3 substrates when possible. If combined, monitor for increased OAT1/3 substrate toxicities. 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
Leflunomide: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy
Nitisinone: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy
Pretomanid: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy
Probenecid: May increase the serum concentration of Ertapenem. Risk X: Avoid combination
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
Tacrolimus (Systemic): Ertapenem may increase the serum concentration of Tacrolimus (Systemic). Risk C: Monitor therapy
Taurursodiol: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk X: Avoid combination
Teriflunomide: May increase the serum concentration of OAT1/3 Substrates (Clinically Relevant). Risk C: Monitor therapy
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
Ertapenem is approved for the treatment of postpartum endomyometritis, septic abortion, and postsurgical infections. Ertapenem may be considered for use as an alternative antibiotic in the treatment of intraamniotic infection (ACOG 712 2017).
Ertapenem is present in breast milk.
The relative infant dose (RID) of ertapenem is <1% when calculated using the highest breast milk concentration located and compared to a weight-adjusted maternal dose of 1 g/day.
In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000).
The RID of ertapenem was calculated using a milk concentration of 0.38 mcg/mL, providing an estimated daily infant dose via breast milk of 57 mcg/kg/day. This milk concentration was obtained following maternal administration ertapenem 1 g IV to five lactating women at 5 to14 days postpartum. Milk concentrations were measured randomly for 5 days following the last dose. The milk concentration within 24 hours of the last dose ranged from <0.13 mcg/mL (lower limit of quantitation) to 0.38 mcg/mL. Peak concentrations were not assessed. Ertapenem was not detectable in the milk of four women and was less than the lower limit of quantitation in one woman by day 5 after the last dose.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother. In general, antibiotics that are present in breast milk may cause non-dose-related modification of bowel flora. Monitor infants for GI disturbances, such as thrush or diarrhea (WHO 2002).
Some products may contain sodium.
Periodic renal, hepatic, and hematopoietic assessment during prolonged therapy; neurological assessment
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.
Absorption: IM: Almost complete
Distribution: Vdss:
Infants ≥3 months and Children: ~0.2 L/kg
Adolescents 13 to 17 years: ~0.16 L/kg
Adults: ~0.12 L/kg
Protein binding (concentration dependent, primarily to albumin): 85% at 300 mcg/mL, 95% at <100 mcg/mL
Metabolism: Non-CYP-mediated hydrolysis to inactive metabolite
Bioavailability: IM: ~90%
Half-life elimination:
Infants ≥3 months and Children: ~2.5 hours
Adolescents and Adults: ~4 hours
Time to peak: IM: ~2.3 hours
Excretion: Urine (~80% as unchanged drug and metabolite); feces (~10%)
Altered kidney function: Unbound AUC increased 1.5- and 2.3-fold in those with mild and moderate renal function impairment, respectively. Unbound AUC increased 4.4- and 7.6-fold in those with advanced renal impairment and end-stage renal disease, respectively.
Older adult: The total and unbound AUC increased 37% and 67%, respectively, in elderly patients relative to younger patients.
Anti-infective considerations:
Parameters associated with efficacy:
Time dependent; associated with time free drug concentration (fT) > minimum inhibitory concentration (MIC).
Organism specific:
Gram-negative organisms (E. coli, K. pneumoniae): Goal: ≥40% fT > MIC (bactericidal) (DeRyke 2011).
S. pneumoniae: Goal: ≥30% fT > MIC (bactericidal) (Xuan 2002).
Population specific:
Critically ill patients in the ICU: Minimum goal: ≥50% fT > MIC; preferred goal: ≥100% fT > MIC (Abdul-Aziz 2020; Al-Shaer 2020; Roberts 2014); some experts favor ≥100% fT > 4 times the MIC (Guilhaumou 2019).
Expected drug exposure in normal renal function:
Cmax (peak): Single dose:
Infants and children 3 to 23 months of age: IV: 15 mg/kg (maximum dose: 1 g): 103.8 mg/L.
Children 2 to 12 years of age: IV: 15 mg/kg (maximum dose: 1 g): 113.2 mg/L.
Adolescents 13 to 17 years of age: IV: 1 g: 155.9 mg/L.
Adults:
IV: 1 g: 155 mg/L.
IM: 1 g: 67 mg/L.
Postantibiotic effect: Minimal bacterial killing continues after ertapenem concentration falls below the MIC of targeted pathogen and varies based on the organism:
S. aureus: ~1.5 hours (Odenholt 1998).
S. pneumoniae: ~2.4 hours (Odenholt 1998).
Gram-negative organisms (Enterobacter cloacae, E. coli, H. influenzae): ≤0.7 hours (Odenholt 1998).
Solution (reconstituted) (Ertapenem Sodium Injection)
1 g (per each): $48.00 - $166.56
Solution (reconstituted) (INVanz Injection)
1 g (per each): $154.39
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