Carbapenems including imipenem, meropenem, ertapenem and
doripenem are broad spectrum antimicrobial agents active against
many gram-positive, gram-negative and anaerobic organisms. They
are highly effective when used appropriately but are also very expensive
relative to potential alternative agents. Indiscriminant use of carbapenems
will also contribute to antimicrobial resistance, decreasing the
effectiveness of the drug class. Many hospitals have established antimicrobial
formularies in the pharmacy to assist in management of expensive
antibiotic drugs. In our institution some antibiotics are restricted
and can only be obtained after approval from the division of infectious
diseases. However, once approved there was no requirement or formal
mechanism in place to re-evaluate the ongoing need for a restricted antibiotic
once the results of microbiology culture and antimicrobial susceptibility
testing became available. The clinical pathology staff in our
microbiology laboratory recently began an antimicrobial stewardship
program related to carbapenems. Each day, a microbiology fellow and
laboratory director review the clinical history, culture results and susceptibility
test results for all patients newly started on a carbapenem,
to determine appropriate versus inappropriate use of the drugs. If objective
data indicate that a patient's infection can be treated using a
non-restricted agent, an email is sent to the clinician as shown in the example
below.