Carbapenem stewardship: positive impact on hospital ecology

Abstract

INTRODUCTION: Excessive group 2 carbapenem use may result in decreased bacterial susceptibility. OBJECTIVE: We evaluated the impact of a carbapenem stewardship program, restricting imipenem and meropenem use. METHODS: Ertapenem was mandated for ESBL-producing Enterobacteriaceae infections in the absence of non-fermenting Gram-negative bacilli (GNB) from April 2006 to March 2008. Group 2 carbapenems were restricted for use against GNB infections susceptible only to carbapenems and suspected GNB infections in unstable patients. Cumulative susceptibility tests were done for nosocomial pathogens before and after restriction using Clinical and Laboratory Standards Institute (CLSI) guide-lines.Vitek System or conventional identification methods were performed and susceptibility testing done by disk diffusion according to CLSI.Antibiotic consumption (t-test) and susceptibilities (McNemar's test) were determined. RESULTS: The defined daily doses (DDD) of group 2 carbapenems declined from 61.1 to 48.7 DDD/1,000 patient-days two years after ertapenem introduction (p = 0.027). Mean ertapenem consumption after restriction was 31.5 DDD/1,000 patient-days. Following ertapenem introduction no significant susceptibility changes were noticed among Gram-positive cocci. The most prevalent GNB were P. aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. There was no change in P. aeruginosa susceptibility to carbapenems. Significantly improved P. aeruginosa and K. pneumoniae ciprofloxacin susceptibilities were observed, perhaps due to decreased group 2 carbapenem use. K. pneumoniae susceptibility to trimethoprim-sulfamethoxazole improved. CONCLUSION: Preferential use of ertapenem resulted in reduced group 2 carbapenem use, with a positive impact on P. aeruginosa and K. pneumoniae susceptibility

Impact of an Antimicrobial Stewardship Initiative on Ertapenem Use and Carbapenem Susceptibilities at Four Community Hospitals

“…to other broad-spectrum antimicrobial agents, such as cefepime and piperacillin/tazobactam following the introduction of ertapenem to a hospital formulary. However, none have reported significant changes in carbapenem susceptibility following ertapenem usage alone, with many methodological problems cited in these studies [38][39][40][41].…”

Carbapenem stewardship: does ertapenem affect Pseudomonas susceptibility to other carbapenems? A review of the evidence

“…Studies have been conducted in different US centres and around the world to evaluate whether introduction of ertapenem to hospital formularies has had an effect on the susceptibility of Gram-negative bacteria to carbapenems and other antibiotics [6][7][8][9][10][11][12][14][15][16]. The studies typically focused on the number of defined daily doses (DDD) of antibiotic used and changes in the susceptibility of P. aeruginosa and, in some cases, Enterobacteriaceae, before and after ertapenem formulary introduction.…”

“…Ertapenem use (DDD) Group April 2006 to March 2008 [12]. Group 2 carbapenem use declined from 61.1 DDD/1000 PD to 48.7 DDD/1000 PD (P = 0.027).…”

“…Multiple single-centre and multicentre ecological studies have recently been conducted that explore whether ertapenem has an impact on hospital ecology [6][7][8][9][10][11][12][13][14][15][16]. Sufficient long-term data are now available to examine whether ertapenem use has resulted in a change in the proportion of carbapenem-susceptible Pseudomonas or in other associated changes in susceptibility to carbapenems.…”

Combined therapy for multi-drug-resistant Acinetobacter baumannii infection – is there evidence outside the laboratory?

“…Such increment in carbapenem resistance may have been associated with abusive prescription of these drugs (Romanelli et al, 2009). Improvement in Acinetobacter susceptibility to carbapenems has been attributed to stewardship programmes, but with weak strength of evidence (Lima et al, 2011).…”