6232 Are we overusing ceftriaxone: using a grenade to clear a hornet nest?

Objectives Bacterial resistance to antibiotics driven by the increasing use of broad-spectrum agents has become a global concern. Inappropriate antibiotic utilisation can result in decreased susceptibility, emergence of multidrug-resistance pathogens, and increased healthcare costs.1 Ceftriaxone is a commonly prescribed antibiotic in the paediatric age group and existing literature had reported a wide variation of justified prescription in drug use evaluations of ceftriaxone, ranging from 12.1% – 78%.2 3 This study is a retrospective audit aimed at assessing the appropriateness of ceftriaxone usage in the paediatric department at a district general hospital in East of England. Methods We retrospectively reviewed the use of ceftriaxone in the paediatric department between 17th to 30th April 2023 (inclusive) by collecting data on patients who were started on ceftriaxone within this period. We reviewed patients' medical notes and collected data on demographics (age, gender), indication for ceftriaxone prescription, presence of red flags for sepsis,4 whether ceftriaxone was changed to oral antibiotic subsequently, discharge diagnosis, and culture results. Results Ceftriaxone was initiated in the department for 33 patients for a range of indications and was determined to be inappropriately prescribed in 18 patients (55%). Appropriate indications include fever in less than 3 months as per NICE guidance, sickle cell crisis, suspected intracranial infection and for those presenting with red flags of sepsis.4 Unjustified use (n=18) comprised of 10 with clear localised infection (tonsillitis, infected eczema, cellulitis, bronchiolitis, urinary tract infection and otitis externa), viral gastroenteritis, unexplained tachycardia with no other symptoms and fever of unclear origin. Of these 18, none had positive bacterial growth in blood cultures and 1 had picornavirus detected on respiratory swab. Ceftriaxone was stopped in 11 patients and was converted to an oral, narrower spectrum antibiotic in 7 patients on day 2 after blood culture was reported to be negative at 36 hours to treat for a ocalized infection. Conclusion A significant proportion of ceftriaxone utilization in the department lacks a valid indication. It was commenced in cases of localized infection, even though established guidelines for first-line, usually a more narrow-spectrum antibiotic in such scenarios are readily available. This indicates an overuse of broad-spectrum antibiotics which could lead to the development of multi-drug resistant organisms and increased healthcare expenses. Addressing this issue requires an intensification of educational initiatives in the department and the implementation of antibiotic control systems specifically focused on ceftriaxone as part of antibiotic stewardship. Our audit proforma can also be adapted to be used for other hospitals. References Barlam TF, et al. Implementing an antibiotic stewardship program: guidelines by the infectious diseases society of america and the society for healthcare epidemiology of America. Clin Infect Dis. 2016;62:e51-e77. Bantie L. Drug use evaluation (DUE) of ceftriaxone injection in the in-patient wards of Felege Hiwot Referral Hospital (FHRH), Bahir Dar, North Ethiopia. Int J Pharm Sci. 2014;4:671–676. Abebe FA, et al. Drug use evaluation of ceftriaxone: the case of Ayder Referral Hospital, Mekelle, Ethiopia. Int J Pharm Sci Res. 2012;3:2191–2195. Fever in under 5s: assessment and initial management (NICE guideline 2019). Available: https://www.nice.org.uk/guidance/ng143.