testing. Lenapenem Sulopenem is in clinical trials for drug resistant urinary tract infections Tomopenem Thienamycin (thienpenem) the first discovered carbapenem Bacterial resistance Enterobacteriaceae Enterobacteriaceae are common pathogens responsible for urinary tract infections, abdominal infections, and hospital-acquired pneumonia. Beta lactam resistance in these pathogens is most commonly due to the expression of beta lactamase enzymes. Between 2007 and 2011, the percentage of Escherichia coli isolates from Canadian hospitals that produce extended spectrum beta lactamases (ESBL) increased from 3.4% to 4.1%; among Klebsiella pneumoniae isolates ESBL producers increased from 1.5% to 4.0%. These strains are resistant to third generation cephalosporins that were developed for the treatment of beta lactamase-producing Enterobacteriaceae and carbapenems are generally regarded as the treatment of choice. More recently, many countries have experienced a dramatic upswing in the prevalence of Enterobacteriaceae that produce both ESBLs and carbapenemases such as the Klebsiella pneumoniae carbapenemase (KPC). As of 2013, 70% of Greek Klebsiella pneumoniae isolates are resistant to third generation cephalosporins and 60% are resistant to carbapenems. The growing prevalence and difficulty of treating such multi-drug resistant Enterobacteriaceae has led to a renaissance of the use of antibiotics such as colistin, which was discovered in the 1950s but rarely used until recently due to unattractive levels of toxicity. Prevalence of carbapenem-resistant Enterobacteriaceae in paediatric intensive care units (Cairo, Egypt) was 24% and various genes of carbapenemases were detected in 80% of carbapenem-resistant Enterobacteriaceae with dominance of blaOXA-48. Pseudomonas aeruginosa and Acinetobacter baumannii Infections caused by the non-fermenting gram-negative bacteria Pseudomonas aeruginosa and Acinetobacter baumanni are most commonly encountered in hospitalized people. These bacteria exhibit an unusually high level of intrinsic resistance to antibiotics due to their expression of a wide range of resistance mechanisms. Antibiotics cross the outer membrane of Pseudomonas and Acinetobacter approximately 100 times more slowly than they cross the outer membrane of Enterobacteriaceae, due in part to their use of porins that can adopt a conformation having a very restricted entry channel. Further, the porin levels may be down-regulated in response to antibiotic exposure. Antibiotic molecules that successfully traverse the porin channels may be removed by efflux pumps. Downregulation of the porin OprD2 is an important contributor to imipenem resistance. Like the Enterobacteriaceae, Pseudomonas and Acinetobacter can express a wide range of antibiotic-deactivitating enzymes, including beta lactamases. Pseudomonas produces an inducible broad spectrum beta lactamase, AmpC, that is produced in response to beta lactam exposure. The combination of