DUE Diligence: Using Drug Use Evaluations of Ciprofloxacin and Meropenem to Identify Opportunities for Antimicrobial Stewardship at a Pediatric Tertiary Care Facility

Background: Drug use evaluations (DUEs) can provide information on antimicrobial prescribing patterns within a hospital. At our institution, we believed that ciprofloxacin and meropenem use would be limited to microbiologically confirmed or classically recommended indications as both agents have restricted use criteria. A DUE of meropenem and ciprofloxacin was conducted to assess hospital-wide use of these agents.

Methods: A retrospective chart review was conducted for all patients receiving greater than 48 hours of ciprofloxacin or meropenem between January 1 and December 31, 2015. Data was abstracted from electronic and paper charts using standardized case report forms. Each prescription was reviewed independently by 2 infectious disease physicians (including one trained in microbiology). Based on clinical syndrome, microbiology, past infecting pathogens and medical history, each prescription was assessed as having a definite, possible or no indication.

Results: A total of 60 courses of ciprofloxacin and 34 courses of meropenem were assessed. For meropenem, 41.2% (n=14) had a definite, 17.6 % (n=6) had a possible and 41.2% (n=14) had no indication. For ciprofloxacin, 28.3 % (n=17) had a definite, 21.7 % (n=13) had a possible and 50 % (n=30) had no indication. For meropenem prescriptions with no indication, 7 of 14 (50%) were started in the PICU, mostly for lower respiratory (n=2), abdominal (n=2) and central nervous system (n=2) indications. For ciprofloxacin prescriptions without an indication, 43% (n=13) were prescribed by general surgery and 77% (n=10) of these were for appendicitis. All patients on meropenem had at least one bacterial culture performed at the time of prescribing, compared to only 41 (68.3%) patients on ciprofloxacin.

Conclusion: Only one-third of prescriptions for meropenem and ciprofloxacin were deemed to be definitively indicated. At our institution, empiric meropenem use without adequate microbiological data should be addressed. ASP efforts focusing on the use of ciprofloxacin for appendicitis and the role of intraoperative cultures in general surgery are indicated. DUEs of broad-spectrum agents are helpful in identifying "covert" antimicrobial use.