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MEC Update on Antibiotic Auto Stop Resolution

Antibiotic Auto Stop Resolution Approved

By Stephen Uman, M.D., and Rekha Murthy, M.D.

Like every other hospital in the nation, Cedars-Sinai is battling increasingly antibiotic-resistant bacteria that put patients at risk of serious, sometimes lethal infections. We have recently emerged seemingly victorious against a highly resistant strain of Acinetobacter through aggressive infection control efforts and are waging ongoing battles with MRSA and VRE. Other such challenges will undoubtedly arise in the future.

One factor that thwarts our efforts (but which is within our control to change) is the unnecessary use of broad-spectrum antibiotics. While such use early in the course of illness when the causative agent is unknown may save the life of a seriously infected patient, the long-term use when not needed leads to the induction of resistance in the bacteria by which we are most challenged. And the wide-spread eradication of more sensitive normal flora can lead to overgrowth with resistant bacteria and fungi and the emergence of C. difficile infections, which themselves lead to frequent morbidity.

It has been well documented that the investment in research and development of new antibiotics has been drastically cut, limiting the option to rely on new antibiotics becoming available to help address the emerging resistant bacteria in hospitals. This has further reinforced the need for improved use of the antibiotics we have available.

In an effort to control these problems, the Medical Executive Committee, acting on a motion referred by the Department of Medicine PIC, has approved a resolution to discontinue broad spectrum antibiotics, such as cefepime, imipenem, meropenem or piperacillin-tazobactam (Zosyn®) after day 5 of therapy. Renewal after day 5 will require justification from the patient's physician responsible for ordering antibiotics. The purpose of this process is to prompt the prescriber to re-evaluate the need for these broad-spectrum antibiotics after a reasonable amount of time and promote thoughtful and judicious use.

The expectation of clinicians is that antibiotics will be "de-escalated" to narrower spectrum antibiotics based on current culture results showing antibiotic sensitive organisms or a lack of identification of multidrug resistant pathogens such as Pseudomonas aeruginosa, or ESBL producer (specifically, this includes patients with negative culture results).

For example, if a patient with an E. coli isolated from an abscess shows "sensitive to all" antibiotics on the testing panel and gets better on piperacillin/tazobactam, there is no reason to continue using this drug when cefazolin would work as well. Even though the de-escalation therapy increases the number of drugs and doses, the antibiotic pressure against gram negative pathogens is decreased dramatically.

If that same patient had showed a negative culture result, strong consideration to de-escalate should be made to other less broad agents, such as cefotaxime plus metronidazole. Again, the antibiotic resistance pressure is reduced with this regimen.

We believe this effort will benefit our patients individually as well as collectively since the resident flora of the institution also have a significant impact on those who come here uninfected, but with time almost inevitably become colonized and then placed at risk of infection with "our" flora. It will also cause our physicians to re-evaluate their patients' needs even when they have initially improved so as to avoid later complications of broad therapies that are not always essential.

The precise process by which physicians will be notified that a broad spectrum antibiotic will be discontinued on day 5 of therapy and the means by which justification for renewal is to be communicated by the patient's physician is currently being determined. The Department of Pharmacy will be providing additional support to help carry out our antibiotic control needs, along with the support of members of the Division of Infectious Diseases.

This effort will certainly not be successful without the cooperation of all physicians who prescribe these antimicrobials. We sincerely hope you will see that this effort is a benefit for all in this challenging era.