Evaluating carbapenem restriction practices at a private hospital in Manila, Philippines as a strategy for antimicrobial stewardship

Abstract

Background Hospital antimicrobial stewardship programs are especially critical in countries such as the Philippines, where antibiotic resistant infections are highly prevalent. At the study institution in Manila, Philippines, a Prior Approval for Restricted Antimicrobials (PARA) is required for non-infectious disease specialists to prescribe certain antimicrobials, including carbapenems. PARA request forms include specification of empiric or definitive therapy based on diagnostic tests. Recommended duration of therapy is typically 3 days for empiric use and 7 days for definitive, with possible extension upon specialist approval. Methods The study took place at an 800-bed tertiary hospital. We performed a retrospective review of patient medical records and laboratory reports dating from January 1 to December 31, 2016. Information related to patient demographics, carbapenem prescription, laboratory diagnosis, and therapy were compiled. Carbapenem prescriptions were classified as ‘adherent’ or ‘non-adherent’ according to clinical guidelines related to infection diagnosis, treatment duration, and de-escalation. Results Of the 185 patients on carbapenem therapy, Prescriptions of carbapenems were either definitive ( n = 56), empiric ( n = 127), or prophylactic ( n = 2) as defined by the ordering provider. 69 out of 185 (37%) prescriptions were deemed non-adherent to guidelines, despite receiving approvals for their respective requests. Of these, 72% were non-adherent due to failure to de-escalate the carbapenem and 28% were non-adherent due to an incomplete course of therapy. Conclusion Despite initial PARA approval for carbapenem therapy, 37% of prescriptions were non-guideline-adherent, highlighting the ongoing challenges in implementing this type of stewardship strategy. In order to increase the effectiveness of PARA, additional approaches may be warranted, including the application of strict policies which reinforce follow-up of available culture results, justification of therapy extension, or referral to an infectious disease specialist. Electronic supplementary material The online version of this article (10.1186/s13690-019-0358-9) contains supplementary material, which is available to authorized users.

Molecular characteristics of carbapenem-resistant Enterobacteriaceae isolated from two tertiary hospitals in the Philippines

“…A study reviewing carbapenem prescriptions in a hospital in Manila observed that 37% were non-compliant to prescription guidelines (Mitchell et al 2019). Policies and strategies to monitor antibiotic resistance and lessen the impact of drivers of antibiotic resistance are needed to mitigate the possible burden brought by these organisms.…”

Hospital pharmacists’ expertise and cooperation towards antimicrobial stewardship in the Philippines: A qualitative study

“…Poor antibiotic use practices are also a challenge in health institutions in the Philippines. A retrospective review conducted in the Philippines highlighted that 37% of the prescriptions concerning carbapenem therapy in a private hospital were for non-guideline adherents 7 . Without a proper course of action to address the root problems of AMR, the world will head towards a post-antibiotic era where effective antibiotics cannot treat minor infections 1 .…”

Genomic Surveillance ofPseudomonas aeruginosain the Philippines from 2013-2014

“…1 Nonetheless, a recent study evaluating carbapenem restriction practices at a hospital in Manila found that 37% of the carbapenems prescriptions were non-compliant, thus pointing to ongoing challenges in antimicrobial stewardship. 5 Between 2010 and 2014, the Philippine Antimicrobial Resistance Surveillance Program (ARSP) reported increasing resistance rates to antibiotics used to treat P. aeruginosa infections such as carbapenems and extended-spectrum cephalosporins ( Figure 1A-B). In contrast, resistance to aminoglycosides and fluoroquinolones has remained relatively stable or slightly decreased in the same period ( Figure 1C).…”