For the majority of healthcare locations worldwide, the “top of the ladder” antibiotic used for clinical sepsis caused by enterobacteraciae is a carbapenem. There are one or two other options, but due to cost, safety and availability issues, for most institutions a carbapenem remains the broadest spectrum option utilised routinely by clinicians.
It would thus make a lot of (common) sense to protect carbapenems as much as possible in order to reduce selection pressure on bacteria, and prevent selection of MDROs such as carbapenem resistant enterobacteraciae (CRE)
I have thus put together a 10 point bundle (in no particular order) on reduction of carbapenem usage which I will call the CURB bundle (nothing to do with pneumonia severity…)
1) Restrict carbapenem usage to specific clinicians: Only allow prescribing of carbapenems where approval has been gained by an Infectious Diseases Physician or Clinical Microbiologist.
2) Restrict the range of carbapenems stocked by the Hospital Pharmacy:- Two would be sufficient.
3) Have a maximum prescription duration for carbapenems:- i.e. the carbapenem prescription would automatically expire after 3-5 days, and would need re-prescribed.
4) Regular audit of carbapenem use:- In terms of total hospital usage volume, and also audit of usage and indications in “high risk areas” such as ICU.
5) Feedback of audit results to all clinicians, both senior and junior, as well as nursing staff and hospital pharmacists.
6) Daily review of individual patients:- Does this patient still need a carbapenem today?
7) Removal of carbapenems from 1st line empirical antibiotic policies for the hospital. This is key to avoid widespread, high volume usage.
8) Removal of carbapenems from 1st line empirical therapy in neutropenic protocols:- Other suitable alternatives (or combinations) are almost always available…
9) Regular Education as to why widespread carbapenem usage is undesirable and where such usage can be safely reduced.
10) “Buy-in” of the above elements by clinical directors and hospital management:- Go right to the top for support.
None of the above are particularly new. However the idea behind a bundle is that the addition of separate elements with modest (and sometimes difficult to measure) effects should add up to a more major and measurable effect when done in composite.
The most important thing is not to take a defeatist attitude if you do have a problem with carbapenem resistant enterobacteraciae. I strongly believe that bundles like the above can be administered safely and can impact on both carbapenem usage and subsequently on CRE rates. I also believe that administration of such bundles is a more practical solution than waiting in “quiet desperation” for the next new even broader spectrum antibiotic to appear.