Objectives To determine the indications for which meropenem was being used and to assess whether these indications adhered to Trust guidelines and national recommendations. This was prompted by the emergence and proliferation of ESBL-producing pathogens and the increase in meropenem use throughout the Trust.1,–,4
Methods The standard used incorporated local and national advice. At least one of the following criteria had to be met for a course to be ‘appropriate’:
▶ Compliance with Trust guidelines (including febrile neutropenia, Pseudomonas aeruginosa eradication in cystic fibrosis, central venous line infections caused by ESBL-producing pathogens and meningitis following neurosurgery).
▶ Recommendation by the infectious diseases (ID) team.
▶ Treatment of infections caused by ESBL-producing pathogens or by multi-drug resistant pathogens.
Data were obtained from the Centralised IV Additive Service and dispensary records of all doses of meropenem prescribed for inpatients from 1st November 2009 to 1st November 2010. Case notes and medication charts for each patient identified were located to gather information regarding the indication and microbiological findings.
Results 102 courses of meropenem were prescribed for 62 patients during the 12 month audit period (seven courses were excluded due to being initiated at other Trusts). 70 courses (68%) were found to be compliant and 32% were found to be non-compliant with the audit standards.
▶ 31 courses were compliant with Trust guidelines, although only 40% of indications were covered by the scope of these.
▶ 32 courses were advised by the ID team. 40% were advised due to ESBL-producing pathogens.
▶ 34 courses were prescribed to treat infections caused by ESBL-producing pathogens. 47% of these were attributable to Klebsiella pneumonia and 30% due to Escherichia coli. These pathogens were responsible predominantly for causing septicaemia and febrile neutropenia.
▶ 44 courses were to cover for non-ESBL-producing pathogens. Most of these courses adhered to Trust guidelines (22), were advised by the ID team (9) or were multi-drug resistant bacteria (5); however 8 courses of meropenem were prescribed despite the bacteria being fully sensitive to cephaolsporins. These were classed as non-compliant.
▶ 24 courses were prescribed in the absence of any microbiological support at all.
Conclusion It is concerning that meropenem use is not adequately controlled by existing guidelines (in the case of septicaemia, where use of meropenem is widespread), by ID recommendation or by the presence of ESBL-producing or multi-drug resistant pathogens. Recommendations to the Trust are to add meropenem to the list of restricted drugs and educating pharmacists to challenge inappropriate use of carbapenems, thus limiting injudicious use.