Introduction of ertapenem into a hospital formulary: effect on antimicrobial usage and improved in vitro susceptibility of Pseudomonas aeruginosa

Abstract

After ertapenem was added to the formulary of a 344-bed community teaching hospital, we retrospectively studied its effect on antimicrobial utilization and on the in vitro susceptibility of various antimicrobial agents against Pseudomonas aeruginosa. Three study periods were defined as preintroduction (months 1 to 9), postintroduction but before the autosubstitution of ertapenem for ampicillin-sulbactam (months 10 to 18), and after the policy of autosubstitution (months 19 to 48) was initiated. Ertapenem usage rose slowly from introduction to a range of 36 to 48 defined daily doses/1,000 patient days (DDD) with a resultant decrease in ampicillin-sulbactam usage due to autosubstitution. Imipenem usage peaked 6 months after the introduction of ertapenem and started to decline coincidently with the increased use of ertapenem. During the second period, imipenem usage decreased (slope = -1.28; P = 0.002). Prior to the introduction of ertapenem, the susceptibility of P. aeruginosa to imipenem increased from 61 to 81% at month 7 but then decreased slightly to 67% at month 9. After the introduction of ertapenem, susceptibility continued to increase; the increasing trend was significant (slope = 1.74; P < 0.001). In the third period, the median susceptibility (interquartile range) was 88% (82 to 95%). This change appeared related to decreased imipenem usage. For every unit decrease in the monthly DDD of imipenem, there was an increase of 0.38% (P = 0.008) in the susceptibility of P. aeruginosa to imipenem in the same month. Ertapenem was effective in our antimicrobial stewardship program and may have helped improve the P. aeruginosa antimicrobial susceptibility to imipenem by decreasing the unnecessary usage and selective pressure of antipseudomonal agents.

FIG. 1.

Usage (DDD) of imipenem and ertapenem and susceptibility of P. aeruginosa to imipenem. Line A indicates the introduction of ertapenem to the formulary. Line B indicates the implementation of the policy of substituting ertapenem for ampicillin-sulbactam.

FIG. 2.

Usage (DDD) and susceptibility of P. aeruginosa to levofloxacin (a), cefepime (b), and piperacillin-tazobactam (c). Line A indicates the introduction of ertapenem to the formulary. Line B indicates the implementation of the policy of substituting ertapenem for ampicillin-sulbactam.