Do you take into consideration a patient's serum albumin level in your decision to use ertapenem?

A 2023 IDSA guidance recommended against the use of ertapenem in critically ill patients as well those with hypoalbuminemia. The latter is based on PK data indicating rapid clearance of the free fraction of the drug, which has approximately 90% protein binding, resulting in lack of attainment of an appropriate fT>MIC pharmacodynamic target. In addition, a number of studies have found that standard b-lactam dosing is often inadequate in septic patients. The authors of the guidance also cite a retrospective study that reported greater mortality. 

It is important to recognize that IDSA guidance is not a guideline - the recommendations do not go through the same rigor. Furthermore, a subsequent correspondence (Phinder-Puente et al., PMID 37721191), while acknowledging the arguments made in the guidance, challenges the conclusion and calls for the generation of higher-quality evidence to address the issue.

But to answer the question – I have not considered serum albumin concentrations relative to the use of ertapenem, but I have seldom used it as initial therapy in critically ill patients, with or without hypoalbuminemia. If, for instance, I choose to recommend a carbapenem for initial empiric therapy in such a patient, I recommend an antipseudomonal carbapenem. When infection is controlled, I do not object to the use of changing to ertapenem. In non-critically ill patients with hypoalbuminemia, I have used ertapenem, but will carefully examine this practice going forward.

This is a sub-question, when do you use ertapenem? I mean outside of IV infusion centers, when do you choose erta over other abx?