Continuous vs Intermittent Meropenem Administration in Critically Ill Patients With Sepsis The MERCY Randomized Clinical Trial

IMPORTANCE Meropenem is a widely prescribed ss-lactam antibiotic. Meropenem exhibits maximum pharmacodynamic efficacy when given by continuous infusion to deliver constant drug levels above the minimal inhibitory concentration. Compared with intermittent administration, continuous administration of meropenem may improve clinical outcomes. OBJECTIVE To determine whether continuous administration of meropenem reduces a composite of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria compared with intermittent administration in critically ill patients with sepsis. DESIGN, SETTING, AND PARTICIPANTS A double-blind, randomized clinical trial enrolling critically ill patients with sepsis or septic shock who had been prescribed meropenem by their treating clinicians at 31 intensive care units of 26 hospitals in 4 countries (Croatia, Italy, Kazakhstan, and Russia). Patients were enrolled between June 5, 2018, and August 9, 2022, and the final 90-day follow-up was completed in November 2022. INTERVENTIONS Patientswere randomized to receive an equal dose of the antibiotic meropenem by either continuous administration (n = 303) or intermittent administration (n = 304). MAIN OUTCOMES AND MEASURES The primary outcomewas a composite of all-cause mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. There were 4 secondary outcomes, including days alive and free from antibiotics at day 28, days alive and free from the intensive care unit at day 28, and all-cause mortality at day 90. Seizures, allergic reactions, and mortalitywere recorded as adverse events. RESULTS All 607 patients (mean age, 64 [SD, 15] years; 203werewomen [33%]) were included in the measurement of the 28-day primary outcome and completed the 90-day mortality follow-up. The majority (369 patients, 61%) had septic shock. The median time from hospital admission to randomizationwas 9 days (IQR, 3-17 days) and the median duration of meropenem therapywas 11 days (IQR, 6-17 days). Only 1 crossover eventwas recorded. The primary outcome occurred in 142 patients (47%) in the continuous administration group and in 149 patients (49%) in the intermittent administration group (relative risk, 0.96 [95% CI, 0.81-1.13], P =.60). Of the 4 secondary outcomes, nonewas statistically significant. No adverse events of seizures or allergic reactions related to the study drugwere reported. At 90 days, mortalitywas 42% both in the continuous administration group (127 of 303 patients) and in the intermittent administration group (127 of 304 patients). CONCLUSIONS AND RELEVANCE In critically ill patients with sepsis, compared with intermittent administration, the continuous administration of meropenem did not improve the composite outcome of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03452839

Automated summary

This double-blind, randomized clinical trial investigated the impact of continuous vs. intermittent administration of meropenem on the composite outcome of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria in critically ill patients. The results showed that continuous administration did not improve the primary outcome at day 28, and none of the secondary outcomes were statistically significant.