Why Doctors Still Prescribe Carbapenems for Certain Infections Despite Updated Guidelines

Introduction to Carbapenems Usage

Carbapenems are a group of powerful antibiotics often used to treat severe bacterial infections. Despite recent changes in medical guidelines, many doctors still prescribe them for treating certain infections caused by Enterobacterales. This article explores the reasons behind this persistent practice.

The Shift in Medical Guidance

Recent studies and guidelines have advised against the liberal use of carbapenems, suggesting alternative antibiotics for less severe cases. The Infectious Diseases Society of America (IDSA) and the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) have released updated guidance to encourage more prudent use of these potent drugs.

Understanding the MERINO Trial

The publication of the MERINO trial led to increased use of carbapenems for treating extended-spectrum beta lactamase (ESBL) producing Enterobacterales infections. The trial's results influenced both practitioners and guidelines to favor carbapenems, especially in complex or severe cases.

Revised Guidelines and Their Implications

In 2020, the IDSA recommended the liberal use of carbapenems for complicated urinary tract infections (UTIs) and other ESBL-producing infections. However, by 2021, ESCMID suggested reserving carbapenems for only the most severe cases, such as septic shock or bacteremia.

In 2023, IDSA updated its recommendations again, advocating for carbapenem stewardship. This meant they removed carbapenems from the list of first-line options for certain infections to help reduce the risk of antibiotic resistance.

Research and Data on Prescription Patterns

To understand how these guidelines have influenced actual medical practices, researchers conducted a retrospective study using data from the PINC AI database. This study aimed to assess the impact of updated guidance on the prescribing patterns of carbapenems in U.S. hospitals.

The study reviewed 30,041 inpatient encounters with extended-spectrum cephalosporin-resistant (ECR) Enterobacterales infections between 2018 and 2021. It found that despite new guidelines, carbapenems were still commonly prescribed, even for less severe infections.

Key Findings from the Data

The study revealed that 17.7% of patients received carbapenems as empirical treatment, while 58.3% received them as targeted treatment. This included a significant number of patients without severe symptoms like septic shock, indicating a gap between guidelines and practice.

Implications for Antibiotic Resistance

Overuse of carbapenems can contribute to antibiotic resistance, a major global health concern. By understanding current prescribing habits, researchers hope to identify areas where more efforts are needed to reduce unnecessary carbapenem use.

Expert Commentary

Erika J. Ernst, PharmD, highlighted that despite the updated guidelines, the study showed no significant change in carbapenem usage. She suggested that a combination of insufficient evidence and confusing guidelines might be responsible for the persistent use of carbapenems.

The Role of Rapidly Evolving Guidance

Dr. Ernst also pointed out that while updated guidelines are essential, they must be clear and supported by robust evidence to influence medical practices effectively. Rapidly changing recommendations can lead to uncertainty among healthcare providers, contributing to inertia in changing prescription habits.

Conclusion and Future Directions

To combat antibiotic resistance effectively, it is crucial to align medical practices with updated guidelines. This requires clear, evidence-based recommendations and ongoing education for healthcare providers. As research continues, the goal is to ensure that carbapenems are used appropriately to preserve their effectiveness for treating severe infections.