Stewardship program on carbapenem prescriptions in a tertiary hospital for adults and children in France: a cohort study

Use of gastrointestinal syndromic multiplex molecular assays and detection of Escherichia coli pathotypes in pediatric wards

Escherichia coli pathotypes are enteric pathogens detected in gastrointestinal multiplex polymerase chain reaction (mPCR), with controversial clinical relevance. Our study aimed to describe clinical features and therapeutic decisions associated with E. coli detections in gastrointestinal mPCR. Children with positive mPCR for enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), Shiga toxin-producing E. coli (STEC), and enteroinvasive E. coli (EIEC)/Shigella identified in two pediatric hospitals over 18 months (2020-2021) were included. We described the frequency of E. coli detection and subsequent modifications in antibiotic strategies. Among the 2,471 mPCRs performed, 338 (14%) tested positive for at least one E. coli pathotype. The patient's mean age was 4.2 years, with 95% experiencing gastrointestinal symptoms. Clinical presentation was generally comparable between E. coli pathotypes. A recent travel abroad was reported in 68/338 (20%) cases and was mainly observed in EIEC/Shigella infections. An E. coli was detected alone in 177/338 (52%) cases and with another virus, bacteria, or parasite in 161 (48%) cases. Multiple enteric pathogens were mainly detected with ETEC (n = 24/26, 92%) and EAEC (n = 82/121, 68%) detections. Antibiotic therapy was prescribed in 136/338 (40%) cases, with initiation based on mPCR results in 69/338 (20%). No antibiotic therapy was discontinued following positive mPCR results. Among the 69 initiations, 31 were deemed inappropriate after retrospective chart review. E. coli detection with mPCR tests may lead to inappropriate antibiotic initiation. Caution is advised when interpreting results from gastrointestinal mPCRs in children, as clinicians may be unaware of their often unclear or irrelevant clinical significance.IMPORTANCEEscherichia coli pathotypes are increasingly detected through the widely used syndromic gastrointestinal multiplex PCR panels. However, their clinical significance and impact on antibiotic therapy in children remain uncertain. This study describes the clinical and microbiological characteristics associated with E. coli detections, as well as the subsequent modifications in antibiotic strategies. It highlights the frequent detection of E. coli pathotypes, often in association with other enteric pathogens, and reveals that nearly half of the antibiotics prescribed following these results were deemed inappropriate. These results underscore the need to enhance clinicians' interpretation of E. coli-positive results and reassess treatment strategies to optimize patient care.

Evaluation of Ceftazidime-avibactam and Ceftolozane-tazobactam Prescriptions in a Tertiary Hospital for Children in France: An Observational Study, 2017-2022

BACKGROUND

Infections caused by drug-resistant Gram-negative bacteria, including carbapenem-resistant Enterobacterales and Pseudomonas aeruginosa, are emerging in pediatric hospitals. New ß-lactam/ ß-lactamase inhibitor combinations exhibit activity against these pathogens; however, there is limited data regarding their use in pediatric populations.

OBJECTIVES

The study aimed to describe the characteristics of ceftazidime-avibactam (CAZ/AVI) and ceftolozane-tazobactam (C/T) prescriptions in children and assess their appropriateness.

METHODS

We retrospectively analyzed all CAZ/AVI or C/T prescriptions in children hospitalized in a French tertiary hospital between 2017 and 2022. All clinical, biological, and pharmacological data were collected prospectively as part of the antibiotic monitoring program set up by our antimicrobial stewardship (AMS) team.

RESULTS

In total, 50 CAZ/AVI and 25 C/T prescriptions were recorded, which concerned 21 and 20 patients, respectively. All patients had an underlying chronic condition. Most prescriptions originated from Pediatric Intensive Care Units and the Department of Pediatric Pulmonology and were mainly initiated for respiratory tract infections (n = 41/50, 82% of the CAZ/AVI prescriptions and n = 14/25, 56% of the C/T prescriptions). P. aeruginosa was the primary pathogen in documented infections for both CAZ/AVI and C/T prescriptions (n = 26/48, 54% and n = 16/19, 84%, respectively). Almost all prescriptions of CAZ/AVI and C/T were considered appropriate (n = 47/50, 94% for CAZ/AVI and n = 23/25, 92% for C/T, respectively) by the AMS team. Both CAZ/AVI and C/T treatments were well tolerated and resulted in clinical success in 33 (66%) and 19 (76%) cases, respectively.

CONCLUSION

Our study suggests that CAZ/AVI and C/T are reasonable treatment options for children infected with Gram-negative pathogens resistant to carbapenems.

Impact of an antimicrobial stewardship program on the appropriate use of carbapenems in a French university hospital (CARBACAI study)

OBJECTIVES

To study compliance with national guidelines for carbapenem (CP) use.

PATIENTS AND METHODS

We performed a two-year prospective monocentric and interventional study in a French university hospital. The study was based on three phases (observation (P1), intervention (P2), and post-intervention (P3)) and ended 10 months after intervention. Compliance of CP prescriptions was based on predetermined criteria.

RESULTS

Among the 330 prescriptions assessed, treatment adequacy on Day 3 increased from 32.3 % (n = 42/130) during phase P1 to 72.2 % (n = 70/97) during phase P3 (p < 0.01), with a significant impact on indications, dosage, and duration of treatment but not on CP choice. There were no significant changes in overall CP consumption.

CONCLUSIONS

Implementing an educational antimicrobial stewardship program for hospital CP proper use had a positive impact. Educational reminders are essential to support these improvements.

Carbapenem prescriptions: Compliance with guidelines in a pediatric hospital

BACKGROUND

This study aimed to describe the use of carbapenems in a pediatric tertiary center and to assess its compliance with national and local guidelines.

METHODS

This retrospective study focused on children who received at least one dose of carbapenems in a tertiary university hospital over a 1-year period (2019). The appropriateness of each prescription was assessed.

RESULTS

In total, 96 prescriptions were collected for 75 patients (median age 3 years [interquartile range, IQR: 0-9]). Most prescriptions were empirical (n = 77, 80%) and mainly concerned nosocomial infections (n = 69, 72%). At least one risk factor for extended-spectrum beta-lactamases was found in 48% (n = 46) of cases. The median duration of treatment with carbapenems was 5 days and it was over 7 days in 38% (n = 36) of cases. The use of carbapenems was considered appropriate in 95% (18/19) and 70% (54/77) of cases when therapy was guided by culture results or was empirical, respectively. De-escalation of carbapenem treatment within 72 h occurred in 31% (n = 30) of cases.

CONCLUSION

The use of carbapenems can be optimized in the pediatric population, even when the initial prescription for a carbapenem is considered appropriate.

Can't keep it SECRET: system evaluation of carbapenem restriction against empirical therapy

Objectives

Carbapenems are appealing agents for empirical use given their broad spectrum of activity; however, selective use is vital in minimizing the risk for development of carbapenem-resistant pathogens. We aimed to examine the impact of carbapenem restriction criteria and a pre-authorization process on utilization and cost savings across a health system.

Methods

This retrospective study was conducted across five adult hospitals. The pre-implementation period was 8 February 2020 to 30 April 2020 and the post-implementation period was 8 February 2022 to 30 April 2022. The primary outcome was to compare the number of orders for carbapenems between the study periods for both the intervention and non-intervention hospitals. Secondary outcomes included projected annual cost and an estimated cost-savings evaluation using a stratified analysis for the intervention and non-intervention facilities to account for more resource-limited settings.

Results

The total number of carbapenem orders decreased between study periods at the intervention hospital (246 versus 61, P < 0.01). At the non-intervention hospitals, orders decreased, although not significantly (333 versus 279, P = 0.58). Meropenem orders decreased by 66% compared with 12% for the intervention and the non-intervention hospitals, respectively (P < 0.001). Annual estimated cost for all facilities was $255 561 in the pre-implementation period compared with $29 593 in the post-implementation period (P < 0.001). Using a stratified analysis to account for available resources, the estimated annual cost saving was $225 968 for the system.

Conclusions

Implementation of carbapenem restriction at the intervention hospital decreased utilization and provided significant cost savings. Furthermore, resource-limited facilities can still experience significant cost savings using a stratified antimicrobial stewardship intervention approach.

Evaluation and Analysis of the Rationality of Clinical Use of Carbapenems in Surgical Departments of a Tertiary Hospital in Southwest China

Purpose

With the increasing frequency and intensity of carbapenem consumption, carbapenem-resistant organisms (CRO) have become a focus of anti-infection research. This study aimed to evaluate the rationality of the clinical use of carbapenems among inpatients in the surgical departments of a tertiary hospital in southwest China.

Patients and methods

A point-score system was established for evaluation based on the clinical practices in surgical departments and selected carbapenem prescriptions from June 2020 to June 2021 for hepatobiliary surgery, gastrointestinal surgery, and neurosurgery in the study hospital. Prescriptions with a total score ≥ 270 were defined as rational. Descriptive statistics were used to describe the characteristics and rationality of the prescriptions. The chi-square test, Mann-Whitney U-test, and Kruskal-Wallis H-test were used to compare characteristics between rational and irrational prescriptions. Linear regression analysis was used to determine the factors affecting the rationality of carbapenem prescriptions.

Results

According to 192 carbapenem prescription records, the median age of patients was 62 years [IQR, 48.0-73.0], and 20% of patients had abdominal infections, 10% had lung infections, 14% had intracranial infections, and 3% had urinary tract infections. 56% of carbapenem prescriptions were irrational. Compared with rational carbapenem prescriptions, irrational prescriptions had a higher proportion of those with inappropriate indications (49% vs 0%, p < 0.05), incorrect variety selection (15% vs 0%, p<0.05), and unreasonable assessment of etiology and efficacy (46% vs 8%, p < 0.05). Linear regression analysis suggested that the diagnosis of cholecystitis (standardized regression coefficient=0.183, p<0.05) and replaced medication (standardized regression coefficient = 0.154, p<0.05) influenced the rationality of carbapenem prescriptions.

Conclusion

Our study shows that the irrational use of carbapenems deserves attention, especially in surgical departments. Interventions for carbapenem use that are based on evaluation criteria should be developed to reduce the emergence and spread of carbapenem-resistant bacteria.

Using national data to describe characteristics and determine acceptance factors of pharmacists' interventions: a six-year longitudinal study

BACKGROUND

In France, hospital pharmacists perform medication order reviews during patients' hospital stays. This activity can be centralized in the pharmacy or carried out directly in the ward, in collaboration with the healthcare team. During this review, pharmacists can make recommendations to optimize therapeutics. Since 2006, they can document their interventions, via the national Act-IP© observatory.

AIM

To determine the characteristics of pharmacists' interventions and their acceptance by physicians in French hospitals.

METHOD

A 6-year observational study of pharmacists' interventions documented on the Act-IP© French observatory between 2009 and 2014 was performed. Multiple logistic regression was undertaken to determine the predictors of physicians' acceptance of interventions.

RESULTS

A total of 194,684 pharmacists' interventions were documented and concerned mainly "dosage adjustment" (25.6%). These interventions were mostly related to drugs from the central nervous system (23.7%). Seventy percent of pharmacists' interventions were accepted by physicians. Acceptance rate was higher when conducted by a pharmacist regularly practicing in the ward (ORa = 1.60, CI 95 [1.57-1.64]). Physicians' acceptance was significantly associated with (1) ward specialty: emergency (ORa = 1.24, CI 95 [1.14-1.35]); (2) type of intervention: "drug discontinuation", "drug switch" (ORa = 1.15, CI 95 [1.12-1.19]) and "addition of a new drug" (ORa = 1.15, CI 95 [1.12-1.19]); (3) drug group: antineoplastic and immunomodulators (ORa = 3.67, CI 95 [3.44-3.92]).

CONCLUSION

This 6-year longitudinal study highlights the role of clinical pharmacists, and particularly the impact of those integrated into wards. This was found to improve intervention acceptance, potentially through collaboration with physicians in pursuit of patient care and drug safety.