Abstract
BackgroundAs meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally.ObjectivesTo retrospectively evaluate meropenem usage at our institution to identify targets for AMS interventions.MethodsPatients receiving meropenem documented with an ‘alert antimicrobial’ form at two tertiary care UK hospitals were identified retrospectively. Clinical records and microbiology results were reviewed.ResultsA total of 107 adult inpatients receiving meropenem were identified. This was first-line in 47% and escalation therapy in 53%. Source control was required in 28% of cases after escalation, for predictable reasons. Those ultimately requiring source control had received more prior antimicrobial agents than those who did not (P = 0.03). Meropenem was rationalized in 24% of cases (after median 4 days). Positive microbiology enabled rationalization (OR 12.3, 95% CI 2.7–55.5, P = 0.001) but rates of appropriate sampling varied. In cases with positive microbiology where meropenem was not rationalized, continuation was retrospectively considered clinically and microbiologically necessary in 8/40 cases (0/17 empirical first-line usage). Rationalization was more likely when meropenem susceptibility was not released on the microbiology report (OR 5.2, 95% CI 1.3–20.2, P = 0.02). Input from an infection specialist was associated with a reduced duration of meropenem therapy (P < 0.0001). Early review by an infection specialist has the potential to further facilitate rationalization.ConclusionsIn real-life clinical practice, core aspects of infection management remain tractable targets for AMS interventions: microbiological sampling, source control and infection specialist input. Further targets include supporting rationalization to less familiar carbapenem-sparing antimicrobials, restricting first-line meropenem usage and selectively reporting meropenem susceptibility.
Highlights
Careful antimicrobial stewardship (AMS) is essential to decelerate the emergence of resistance to currently available drugs, and preserve their efficacy
The efficacy of AMS interventions and implementation is increasingly studied, with a recent Cochrane Library review published in 2017,2 and identifying specific elements of clinical practice to target with such interventions is valuable
This retrospective, in-depth evaluation of real-life meropenem usage has identified several tractable targets for carbapenem-sparing AMS interventions that could be incorporated into national AMS guidance, such as the recently evaluated Scottish Antimicrobial Prescribing Group (SAPG) quality improvement programmes (QIPs).[8]
Summary
Careful antimicrobial stewardship (AMS) is essential to decelerate the emergence of resistance to currently available drugs, and preserve their efficacy. Trials of AMS interventions demonstrate efficacy in reducing rates of both infection and colonization with antimicrobial-resistant (AMR) bacteria.[1,2] Importantly, the associated reduction in inpatient antimicrobial usage has not been associated with an increase in mortality. In comparison with other b-lactams, resistance to carbapenems is less prevalent; their broad spectrum of antimicrobial activity remains relatively preserved. The prevalence of carbapenem resistance throughout the world is increasing and usage of carbapenems should be restricted, unless absolutely necessary, to maintain their efficacy.[3,4,5,6,7] Recognizing this, carbapenems are considered ‘critically important’ antimicrobials by the WHO. As meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally
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