Tractable targets for meropenem-sparing antimicrobial stewardship interventions

Abstract

Background As meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally. Objectives To retrospectively evaluate meropenem usage at our institution to identify targets for AMS interventions. Methods Patients receiving meropenem documented with an ‘alert antimicrobial’ form at two tertiary care UK hospitals were identified retrospectively. Clinical records and microbiology results were reviewed. Results A 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. Conclusions In 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.

Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study

“…Among patients admitted to critical care, a high proportion received piperacillin–tazobactam, carbapenems, and glycopeptides, with evidence of co-prescription of carbapenem and glycopeptide ( figure 3D ), as well as piperacillin–tazobactam and carbapenem ( figure 3D ). Carbapenems accounted for 3·8% of all prescriptions, whereas carbapenem-sparing Gram-negative active alternatives 14 were less frequently prescribed (co-trimoxazole 1·5%, temocillin 0·3%, and aztreonam 0·2%). Almost half of prescriptions involved WHO AWaRe watch antimicrobials ( appendix p 8 ).…”

Impact of the Acceptance of the Recommendations Made by a Meropenem Stewardship Program in a University Hospital: A Pilot Study

“…In cases where meropenem was judged unnecessary, the physician in charge tended to be more likely to follow up on the audit's recommendation to discontinue than they were in cases where meropenem was judged to be excessively broad spectrum (83.3%, OR 3.05 (1.03-8.99), p = 0.04) (see Figure 2). Rusell et al [26] retrospectively analyzed meropenem use in 107 inpatients. In 14 of them, a meropenem recommendation was made, and in eight patients (60%), the recommendation was to discontinue its use.…”

Antimicrobial rationing in orthopaedic surgery

“…Evaluations of these interventions have demonstrated their efficacy in reducing rates of both infection and colonization with antimicrobial-resistant bacteria. 42 - 44 The prevalence of carbapenem (e.g. meropenem) 45 , 46 and glycopeptides (e.g.…”