J Arancibia 🦠

#ICU News: Recarbrio is disappearing from the U.S. market. Not because it failed. Not because of a safety signal. Not because resistant bacteria disappeared. Merck is discontinuing it as part of a portfolio decision. I guess “portfolio decision” is the code name for “not profitable drug.” And that should make every intensivist, ID physician, and pharmacist uncomfortable. Recarbrio is the trade name of imipenem/cilastatin + relebactam. The FDA approved it in 2019 for complicated infections in adults with limited or no alternatives. In 2020, it was approved for hospital- and ventilator-associated bacterial pneumonia. And in 2025, its indication expanded to children ≥ 2 kg. Why did we need it? Because relebactam inhibits important β-lactamases -including KPC and AmpC-helping restore imipenem activity against some extremely difficult Gram-negative infections. And here is where the story gets interesting. Drugs like this are supposed to be used **selectively**. That's good antimicrobial stewardship. But it creates a difficult economic model. Recarbrio launched at roughly $268/vial, summing up to roughly $10,000 for a 10-day course. More recently, wholesale list pricing reached approximately $8,141 for 25 vials, or about $326/vial. Hospitals are supposed to reserve antibiotics like this for patients who truly need them. So the better we steward the antibiotic, the less frequently we use it. And the less frequently we use it, the smaller its commercial market. **That is the antibiotic paradox.** We need new antibiotics to be valuable enough to develop but rarely used enough to preserve their effectiveness. Recarbrio isn't the first warning. And it won't be the last if we continue expecting critical antibiotics to survive on a conventional “sell more doses” business model. One important detail: This does not appear to be a global withdrawal. Recarbrio remains authorized in Europe. So, at least for now, this appears primarily to be a U.S. market exit. Will this leave us defenseless? No. Other agents cover many of the same resistant organisms. But that's not really the point. The point is what happens when we finally develop another weapon against multidrug-resistant bacteria and discover that the economics reward selling antibiotics often, while stewardship requires us to use them rarely. Maybe Merck has a better explanation. I’d genuinely like to hear it. Antibiotic resistance is accelerating. Our antibiotic business model is moving in the opposite direction. #medtwitter #idtwitter #foamed