Opportunities to enhance antibiotic stewardship: colistin use and outcomes in a low-resource setting

Abstract

Background: Colistin use is increasing with the rise in MDR Gram-negative infections globally. Effective antibiotic stewardship is essential to preserve this antibiotic of last resort.

Objectives: This study investigated stewardship and safety errors related to colistin use to identify opportunities for improvement.

Patients and methods: A prospective descriptive study involving all patients 13 years and older treated with colistin at a tertiary hospital in Cape Town, South Africa, between August 2018 and June 2019. We collected clinical, laboratory and outcome data and assessed provided treatment for stewardship and safety errors.

Results: We included 44 patients. Treatment errors were identified for 34 (77%) patients (median = 1), most commonly inadequate monitoring of renal function (N = 16, 32%). We also identified no rational indication for colistin (N = 9, 20%), loading dose error (N = 12, 27%); maintenance dose error (N = 10, 23%); no prior culture (N = 11, 25%); and failure to de-escalate (2 of 9) or adjust dose to changes in renal function (6 of 15). All cause in-hospital mortality was 47%. Amongst survivors, median ICU stay was 6 days and hospital stay more than 30 days. Eight (18%) patients developed renal injury or failure during treatment. Three (7%) patients in this study were found to have colistin-resistant organisms including two prior to colistin exposure.

Conclusions: This study has identified opportunities to enhance colistin stewardship and improve efficacy and safety of prescription. The appearance of colistin-resistant organisms reinforces the urgent need to ensure effective and appropriate use of colistin.

Figure 1.

Summary of South African and international colistin dosing guidelines by total daily dose according to estimated glomerular filtration rate.

Figure 2.

Box-and-whisker plot of the number of stewardship and safety errors found overall, by level of care and by discipline. Central line indicates the median number of errors found, box indicates the IQR and whiskers indicates the range.