Efficacy and safety of antibiotics in the treatment of multidrug-resistant Acinetobacter baumannii infections: A systematic review and Bayesian network meta-analysis.

OBJECTIVES

This study aims to compare the efficacy and safety of antimicrobial regimens for multidrug-resistant Acinetobacter baumannii (MDR A. baumannii) infections using a Bayesian network meta-analysis (NMA).

METHODS

The PubMed, Embase, Web of Science, Scopus, and Cochrane Library databases were searched from inception through 6th January 2025, for randomized controlled trials (RCTs) and cohort studies. The primary outcome was all-cause mortality; secondary outcomes included clinical improvement, microbiological cure, and nephrotoxicity. A random-effects NMA estimated odds ratios (ORs) with 95% credible intervals (CrIs) and ranked regimens using the surface under the cumulative ranking curve (SUCRA).

RESULTS

The Bayesian NMA included 10 RCTs and 38 cohort studies (14 regimens; 7 300 patients), with cohorts contributing 80.6% of the data. Compared with tigecycline, cefiderocol-based therapies (combination: OR = 0.41, 95% CrI: 0.22-0.77; monotherapy: OR = 0.44, 95% CrI: 0.27-0.76) and sulbactam-durlobactam (OR = 0.42, 95% CrI: 0.15-1.20) were associated with reduced mortality (very low certainty). Sulbactam-durlobactam also ranked highest for clinical improvement (OR = 5.79, 95% CrI: 1.62-21.46, SUCRA 91.0%) and microbiological cure (OR = 8.66, 95% CrI: 1.92-41.01, SUCRA 98.2%; very low certainty). Colistin-based regimens had the highest nephrotoxicity (combination: OR = 8.21, 95% CrI: 1.41-59.35; monotherapy: OR = 7.75, 95% CrI = 1.81-40.82; very low certainty).

CONCLUSIONS

Sulbactam-durlobactam ranked highest for clinical improvement and microbiological cure, while cefiderocol-based therapies scored highest for mortality reduction in our NMA. However, the evidence was largely derived from observational studies with very low certainty. Further A. baumannii-specific RCTs are needed to confirm these findings.