So this was in a paediatric ICU in South Africa. A relatively well-resourced ICU. The ICU– well, the hospital had access to laboratory. There was no formal stewardship programme or formal stewardship team in the hospital at the time. And our approach to managing antimicrobials was really with the microbiologist, myself, visiting the ICU on a weekly basis and joining their rounds. I would bring along a set of laboratory results that had been generated over the last couple of days from the ICU. We’d discuss appropriate antibiotic therapy if necessary and the issues around infection control. And it was a rotating thing, so I would interact with different ICU consultants on each round.
So the case in question is that of a six-year-old who’d been admitted fairly recently with clear clinical symptoms and signs of meningitis and had depressed level of consciousness. She had no lumbar puncture done, because she was too ill, but a blood culture was taken on admission, and then she was commenced empirically on meropenem. When I got to the round, this was probably 48 hours after admission, and we had a blood culture result available. We had isolated Steptococcus pneumoniae from blood cultures. And this organism was susceptible to both penicillin and ceftriaxone based on MIC testing. So some background of respiratory and meningeal pathogens in South Africa. And this is data from the National Surveillance Programme run by the German system.
It showed that overall in South Africa we had, although concerning rates of resistance or nonsusceptibility to penicillin, very little resistance to ceftriaxone. And that had remained stable over a number of years. So this case took place before these data came out. But at that stage, our penicillin and ceftriaxone nonsusceptibility rates would have been even lower. So guidelines at that stage– and the guidelines still currently are– for respiratory infections, we would still use penicillin/amoxicillin as empiric therapy. High-level penicillin resistance is still relatively rare. And for meningitis, guidelines at that stage, and current guidelines still make use of intravenous ceftriaxone in high doses. And only use alternative agents if the ceftriaxone MIC was greater than 1.
So the first discussion point was, why did you start meropenem empirically for a child who’d been admitted with meningitis? There was no history of prior hospital exposure. No history of neurosurgical procedures or shunts, which might predispose a patient to infection with unusual organisms, particularly Gram negatives. And at that stage, we believed that we had really few ESBLs and resistant Gram negatives causing community-wide infections. And this was, essentially, a community-acquired infection, most likely meningitis. Most likely pathogens would have been Strep pneumoniae, possibly meningococcus. Haemophilus influenzae type B was uncommon at that stage due to vaccination. And appropriate therapy would have been ceftriaxone.
And generally the response– and this is not a unique response– was that the patient was critically ill and I needed a bigger gun to treat the patient. So the follow-up discussion was that you’ve chosen meropenem empirically. We now have an organism compatible with the clinical diagnosis which is susceptible to narrow-spectrum antibiotics. Don’t you want to de escalate to penicillin or maybe even ceftriaxone? And the response was, she is getting better on meropenem. I don’t want to change the antibiotics because the patient is responding. And this is also not an uncommon response. So I’m going to take us to the ISC stewardship checklist. And there are a number of checklists and guidelines on what to do for stewardship.
This is a 10-point guideline. It’s quite useful to the points and how our case matches up to the recommendations in this checklist. So the first point is to take appropriate samples, which were done. Blood culture was collected. CSF was not possible. To only treat or use antibiotics when there’s a confirmed or strongly suspected bacterial infection. This patient had a clinical diagnosis of meningitis, clearly bacterial. Needs to be covered, and decision to use an antibiotic was clearly appropriate. The third point in the checklist is to tailor empiric therapy to the local setting. That was clearly not done in this case. The fourth point is to use the correct dose, route, and duration.
And here, this was not recorded or discussed in the ward round. And I would say this is partly– well, at that stage due to we didn’t have a standard approach to antimicrobial stewardship, and we tended to focus on just the choice. And that half, but I think that’s a half that reflects lack of attention to detail on both my part and the ICU’s part. Use combinations only if proven benefit. This child was only on a single agent. Avoid antibiotics with resistance potential. This is a good idea. It’s difficult to know which antibiotics have higher resistance potential than others.
I think certainly given what we’re seeing at the moment with carbapenemases and carbapenem-resistant organisms, we should certainly be looking to avoid carbepenems where possible. And I would score a half of this point, although maybe that’s generous. Source control was not applicable. De-escalation was not done. That was clearly a problem. Recommendation to stop antibiotics if bacterial infection is excluded. In this case, it was included so it was actually not applicable. And to use a team, which is where our Programme at that stage fell apart quite heavily.
So overall, this case scores a 60% for antimicrobial stewardship, although that’s probably a generous 60%, since some of the items, such as source control and stopping if the infections exclude didn’t actually apply to this case at all. There are three key areas where stewardship fell apart in this case. And just to talk a little bit about why the stewardship Programme didn’t work here. Firstly is this perception that bigger is better when choosing an antibiotic. And that’s not the case. If you’ve got a susceptible organism, it responds as well to an appropriate narrow-spectrum agent as it does to a broad-spectrum agent. And a lot of that is linked to training and experience and sometimes fear of failure.
Some people believe that the marketing also plays a role here– so representatives from pharmaceutical companies trying to promote their products, which is part of their job, but careful balance needs to be made between promoting and not over-promoting. There’s a clear role for a functioning AMS committee in this sort of setting to review inappropriate use and feedback to prescribers where use is inappropriate around how it could be improved and support decisions of individual prescribers where it is appropriate. And lastly, guideline availabilities. The guidelines– that set hadn’t been published. But our local antibiotic policy did stipulate the use of ceftriaxone for meningitis, so guidelines were available for meningitis.
And again, it’s a question of whether people believe it, need to be held accountable to particular guidelines. And that’s another challenge for any AMS committees to get buy-in to guidelines and enforce use of the guidelines. And then why de escalation wasn’t done. I think part of it was the fact that I was a junior microbiologist at the time, speaking to a senior ICU consultant, and it’s a lack of confidence and kind of appreciation of different roles of different members of the team. The attitude of “if it ain’t broke, don’t fix it” is also one I’ve come across repeatedly. So patient on a broad-spectrum agent. We don’t want to de-escalate because the patient’s getting better.
Why do we want to fix a winning combination? And I can only point to this quote, ostensibly by Colin Powell, is that that is “the slogan of the complacent, the arrogant, or the scared.” It’s an excuse not to do something. It’s not a reason not to do something. It’s important to have a prescribing champion in any AMS Programme so that if you do find a prescriber who is not adhering to guidelines, to get an experienced clinician who is prescribing antibiotics to go and speak to the person at a one-to-one level. And certainly reinforces the need for teamwork. I think one of the reasons that antibiotics were used appropriately in this case was that there was no team approach.
It was I’ve got one opinion, the consultant’s got another opinion, and the ICU consultant’s opinion overrode mine since at that stage, he was the prescribing clinician.