Issue: May 2020

Disclosures: Lesher reports no relevant financial disclosures.
April 21, 2020
2 min read

Removing ESBL labeling in EMRs reduces carbapenem use for infections

Issue: May 2020

Disclosures: Lesher reports no relevant financial disclosures.
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Mark Lesher

Using Clinical and Laboratory Standards Institute, or CLSI, revised breakpoints and omitting extended-spectrum beta-lactamase, or ESBL, labeling in electronic medical records decreased the prescribing of carbapenem antibiotics and increased beta-lactam/beta-lactamase inhibitor use for infections due to ESBL producers, according to a single-center retrospective chart analysis.

“In infectious diseases, and specifically the antimicrobial stewardship program, we are always trying to optimize antibiotics for our patients, as well as engage microbiology to enhance how reporting of cultures and impact clinician decision-making,” Mark Lesher, PharmD, MBA, BCPS, antimicrobial stewardship program pharmacist at Penn State Health, told Healio.

Previously, Lesher and colleagues changed the microbroth dilution antimicrobial susceptibility test panel to comply with the CLSI minimum inhibitory concentration revised breakpoints. They found that changing from a panel that included ESBL confirmatory testing to one that does not eliminated the microbiology laboratory’s standard reporting of the presence of an ESBL within the electronic medical record.

“While possible presence of an ESBL may be inferred based on susceptibility patterns (eg, resistance to third-generation cephalosporins and aztreonam and susceptibility to cephamycins), this knowledge is not widespread amongst clinicians,” Lesher said. “Since we strive to ensure our changes do not harm patients, we wanted to study the impact of this change on our antibiotic prescribing within Hershey Medical Center.”

Lesher and colleagues performed a retrospective, noninterventional chart analysis using the Microscan LabPro Command Center database to detect adult and pediatric patients with positive cultures for ESBL-producing Enterobacteriaceae during the 6-month periods both before and after revised breakpoints were put into effect. They identified 285 ESBL-producing bacteria in 263 patient encounters.

More isolates were found after the breakpoints were put into place (n = 170) than before (n = 115).

Study findings demonstrated that the definitive prescribing of carbapenems declined from 48.4% prior to the implementation of the revised breakpoints to 16.1% after (P = 0.01). The use of beta-lactam/beta-lactamase inhibitor combinations (BL/BLI) increased from 19.4% before the revised breakpoints to 61.3% after (P = 0.002).

According to Lesher, these results confirm the idea that carbapenems should be the preference for bloodstream infections due to ESBL-producing organisms, although BLBLIs may still be appropriate for urinary tract infections.

“Our study is unique in that we assessed the impact of removing potentially informative comments — in this case, the term ’ESBL‘ — and observed a significant reduction in carbapenem use and an associated increase in BLBLI for infections due to ESBL-producing organisms,” Lesher concluded. “The removal of ESBL comments in the EMR resulted in a reduction in definitive carbapenem use and an increase in BLBLI use, which may have significant clinical implications. Our findings highlight the continued importance of collaborative relationships between clinical microbiology and antimicrobial stewardship programs to aid clinicians in choosing optimal antimicrobial therapy.” – by Caitlyn Stulpin


Lesher MD, et al. Infect Control Hosp Epidemiol. 2020;doi:10.1017/ice.2020.4.

Disclosures: Lesher reports no relevant financial disclosures.