Meropenem is a broad-spectrum antipseudomonal carbapenem antibiotic. Controlling the prescribing of carbapenems is important in our efforts to curb the development of carbapenem-resistant Gram-negative organisms, which already pose a serious health threat to many parts of the UK.
At Southport and Ormskirk Hospital NHS Trust, meropenem is a restricted antibiotic, and consumption is measured quarterly each financial year. An alarming increase was noted over 2014–2015 from an average of 355 defined daily doses (DDDs) per month in 2013–2014, to 698 DDDs per month during the final quarter of 2014–2015. The major driver for this was thought to be an increase in the rate of Clostridium difficile infections in the Trust at the time, which lead prescribers to use meropenem (perceived as an antibiotic with lower risk of C. difficile) in place of cephalosporins, which were recommended at the time in the local antibiotic guidelines for a number of common infections.
In response to this, the antimicrobial management team (AMT) reviewed local antimicrobial guidelines in an effort to introduce therapeutic alternatives with lower C. difficile risk. In many cases, the aminoglycoside gentamicin was substituted for a cephalosporin when empirical Gram-negative bacterial cover was required, particularly in patients with penicillin allergy. Changes to facilitate safe and effective use of gentamicin included an update of the local gentamicin dosing and monitoring protocol, a supplementary gentamicin prescription sheet, release of an electronic dose calculator and procurement of a mobile app platform to host local antimicrobial guidelines. These changes came into effect during August–November 2015. Training for these changes was given to the pharmacists, foundation-level doctors and nursing staff during this period.
Following these interventions, meropenem consumption fell to a total of 2,704 DDDs in financial quarters 3 and 4 of the year 2015–2016, down from 3,546 DDDs in the same quarters of 2014–2015, and fell further to 2,497 DDDs over this period in 2016–2017. Interestingly, gentamicin consumption more than doubled from 2014–2015 to 2016–2017, while cephalosporin consumption went down, suggesting that the reduction in meropenem consumption was offset by increased gentamicin use, rather than alternative antibiotics with higher C. difficile risk.
A Commissioning for Quality and Innovation target (also known as a CQUIN) — a national UK government quality improvement incentive — was introduced in 2016–2017 to reduce carbapenem consumption in English trusts by 1% against the baseline year of 2013–2014. The Trust failed to reach this target, despite the interventions described. Further initiatives were therefore introduced by the AMT in 2017 to improve meropenem prescribing.
Since April 2017, a daily review of meropenem prescriptions (informed by reports from the pharmacy dispensing system) has been carried out by the AMT. In addition, a retrospective audit (December 2016–May 2017) of meropenem prescribing in the trust was conducted. The audit found that 41% of meropenem prescriptions were outside of the restrictions specified in the local antimicrobial guidelines, and 13% of these were also considered clinically inappropriate. The audit found that in almost all cases (93%) the non-compliant prescriptions were from medical rather than surgical specialities, and particularly from respiratory medicine (43%). These results were fed back to the teams, and an action plan was put in place to improve awareness of the restricted antibiotic system.
Meropenem consumption during the second quarter of 2017–2018 was 988 DDDs, down from a baseline of 1,331 DDDs during the same quarter of 2016–2017. The action plan from the audit and the daily targeted review of meropenem prescriptions are ongoing, and it is hoped that meropenem consumption will continue to reduce further. Electronic prescribing is expected to provide new opportunities to monitor and manage the consumption of restricted antimicrobials, including meropenem, when it is introduced at Southport and Ormskirk Hospital NHS Trust.
In summary, these interventions have shown that consumption of valuable broad-spectrum antibiotics can be successfully managed by a combination of fit-for-purpose, accessible antimicrobial guidelines and by robust clinical review and audit.
John Gwilliam, lead pharmacist – antimicrobials
Katherine Gray, consultant medical microbiologist and antimicrobial lead
Southport and Ormskirk Hospital NHS Trust