Management of MDR/XDR severe infections in the critically ill.

Purpose of review: This review aims to summarize current recommendations for the management of serious infections, such as bloodstream infections (BSIs) and ventilator-associated pneumonia, caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) pathogens, focusing on evidence from randomized controlled trials (RCTs) and emerging treatment options.

Recent findings: Vancomycin, linezolid, and daptomycin represent the main therapeutic options for the management of methicillin-resistant Staphylococcus aureus infections; among newer agents, ceftobiprole has recently gained approval for BSI treatment. For vancomycin-resistant Enterococcus faecium BSIs, linezolid and daptomycin remain commonly employed despite the lack of comparative RCTs guiding treatment decisions. The management of MDR/XDR Gram-negative infections is challenging, owing to sparse clinical trials for robust guidance and rapid emergence of diverse resistance mechanisms. New beta-lactam/beta-lactamase inhibitor combinations remain the cornerstone of treatment for carbapenem-resistant Enterobacterales and carbapenem-resistant Pseudomonas aeruginosa. Cefiderocol and the combination of ceftazidime-avibactam plus aztreonam represent the current last-resort options for metallo-β-lactamase producers. For carbapenem-resistant Acinetobacter baumannii, sulbactam-durlobactam has demonstrated at least comparable activity compared to colistin but is unavailable in most countries.

Summary: Optimal management of serious infections by MDR/XDR pathogens requires up-to-date knowledge of evolving treatment options and resistance mechanisms. Further high-quality clinical trials are needed to guide evidence-based therapy.