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Challenges and Opportunities in Implementing Antimicrobial Stewardship for Enhanced Carbapenem Utilization

In the face of voluminous, shifting guidance endorsing antimicrobial stewardship, including limited instructions for carbapenem use, numerous hospitals are observed persisting with carbapenem application in ways incompatible with the most recent recommendations. A multicenter study, arguably the largest analysis of carbapenem prescribing patterns over time, finds current usage of carbapenem in treating extended-spectrum ß-lactamase (ESBL)-producing Enterobacterales in accordance with the 2020 guidelines from the Infectious Diseases Society of America (IDSA) but noticeably exceeding and deviating from the updated 2023 bounds.

Dr. Morgan Walker and her colleagues from the National Institutes of Health Antimicrobial Resistance Outcomes Research Initiative (NIH-ARORI) underscore an evident stewardship gap between the present use of carbapenems at US hospitals and the new, as well as emerging practice recommendations from American and European infectious disease communities. The IDSA’s 2023 update shifts the priority towards stewardship and confines the conditions for prescribing carbapenems. This goes against the 2020 guidance, which endorses carbapenems as the primary line of treatment for complex cystitis and other non-urinary tract infections (UTIs) stemming from ESBL-producing Enterobacterales.

This research reveals a tangible separation between present practices concerning the application of carbapenems in US healthcare facilities and the updated professional advice from infectious disease societies. With new instructions supporting measured use of carbapenems for certain inflections, such as complex UTIs caused by ESBL-producing Enterobacterales, the study uncovers a consistent high reliance on carbapenems for non-serious infections. This clearly demonstrates the difficulties in effectively transitioning updated guidelines into clinical practice.

This retrospective cohort study, which took place from January 2018 to December 2023, involved consulting the PINC AI database which comprises approximately 25% of all US hospital admissions. The study cohort included over 30,000 adults checked into 168 US hospitals with biological evidence of extended-spectrum cephalosporin-resistant Escherichia coli or Klebsiella pneumoniae.

There are calls for advanced strategies like proactive audits and feedback, as well as alterations to susceptibility results to help direct ideal treatment as education alone might be insufficient to inspire change. Dr. Walker and her fellow researchers also recognize the daunting task of incorporating new guidance into clinical practices. Despite 97% of acute care hospitals in the US implementing the core components of an antimicrobial stewardship program (ASP), these programs can differ vastly from institution to institution across the US. For improved effectiveness, there is a need for expedited dissemination of updated expert guidelines along with better comprehension of the optimum strategy for guidance application and information distribution.


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