Assessing the clinical impact of carbapenem pre-authorisation on clinical outcomes in a setting with a high prevalence of extended-spectrum beta-lactamase producing organisms: a focus on the Middle East

BACKGROUND: Data on carbapenem pre-authorisation in hospitals with a high prevalence of extended-spectrum β-lactamase (ESBL) producing organisms is scarce. Therefore, the aim of this study was to evaluate the impact of implementing a carbapenem pre-authorisation policy on patients admitted to our acute care floors, focusing on appropriateness of use and the clinical outcomes. METHODS: A retrospective observational quasi-experimental study was conducted comparing data from adults with active infections admitted to the acute care floors during the pre-restriction period (December 2021-May 2022) and the post-restriction period (June 2022-December 2023) who were prescribed carbapenems (ertapenem or meropenem). RESULTS: A total of 244 patients met the inclusion criteria, with 131 in the pre-implementation period and 113 in the post-implementation period. The proportion of appropriately indicated carbapenem use was significantly higher in the post-restriction group at 69.9% (79) compared with 55.7% (73) in the pre-restriction group (p=0.025). The 30-day all-cause mortality rate was significantly lower in the post-restriction group at 8 (7.1%) vs 26 (19.8%) in the pre-restriction group (p=0.005). Length of hospital stay was also significantly reduced in the post-restriction group, with a median of 6 days compared with 9 days in the pre-restriction group (p=0.002). Additionally, the 30-day readmission rate was lower in the post-restriction group at 20.4% (23) compared with 32.1% (42) in the pre-restriction group (p=0.043). The multivariate logistic regression analysis indicated that the quick Sequential Organ Failure Assessment (qSOFA) score was the only independent risk factor for mortality (OR 3.2; 95% CI 1.3 to 7.9; p = 0.013), while neither the carbapenem used nor the restriction policy demonstrated a significant association with mortality. CONCLUSION: Despite the high prevalence of ESBL-producing organisms, the carbapenem pre-authorisation policy proved effective in optimising their use, particularly with respect to appropriateness and clinical outcomes. Larger studies are warranted to corroborate these findings.