Caspofungin is an echinocandin that

Caspofungin is an echinocandin that inhibits the synthesis of β(1,3)-d-glucan, an essential component of the A-443654 cost of susceptible Aspergillus and Candida species. It has been approved by the FDA for use in adults and pediatric patients (⩾3months of age) for empirical therapy for presumed fungal infections in febrile, neutropenic patients; treatment of candidemia and the Candida infections (intra-abdominal abscesses, peritonitis, and pleural space infections); treatment of esophageal candidiasis; and treatment of invasive aspergillosis in patients who are refractory to or intolerant of other therapies (e.g., amphotericin B, lipid formulations of amphotericin B, itraconazole) (Merck Sharp et al., 2013).
Imipenem is a Thienamycin that inhibits cell-wall synthesis. Cilastatin is a dehydropeptidase I inhibitor that prevents renal metabolism of imipenem. Imipenem has been approved by the FDA for the treatment of lower respiratory tract infections (LRTI), skin and skin structure infections (SSSI), and intra-abdominal and gynecologic infections caused by susceptible strains of microorganisms (Merck Sharp et al., 2013).
Meropenem is a carbapenem that penetrates bacterial cell walls to reach penicillin-binding-protein targets, thus inhibiting cell wall synthesis, resulting in cell death. The FDA has approved meropenem for the treatment of intra-abdominal infections (complicated appendicitis and peritonitis), bacterial meningitis, and complicated skin and skin structure infections (cSSSI) caused by susceptible strains of microorganisms. It is useful as presumptive therapy in the indicated condition prior to identification of causative organisms (AstraZeneca Pharmaceuticals LP, 2013).


Results and discussion
Duration of therapy analysis showed significant reduction in the average duration of use of imipenem and meropenem, in the second and fourth periods of the study. Average Caspofungin duration of therapy was (12.15, 7.70, 13.15, 10.97) days, for Periods I, II, III, and IV respectively (F(3,93)=0.84 , p=0.4756), while average imipenem duration of therapy was (10.52, 7.61, 8.86, 6.68) days, for the same periods respectively (F(3,214)=3.60, p=0.0144). Meropenem duration of therapy was (12.74, 7.38, 10.35, 7.99) days for the same periods respectively (F(3,240)=3.95, p=0.0089). DBD analysis showed similar results for the same periods and drugs.
Non-significance of reduction of caspofungin DBD resulted from the drug being used in culture-negative patients, as illustrated in Fig. 1, and failing to de-escalate therapy appropriately (Levy et al., 2012). Off-label (Mukattash et al., 2011) and prophylactic prescribing may impair control of caspofungin. In these cases causative organisms were not identified and drug therapy was empirical. The analysis was not expanded to the number of microorganisms and number of infection sites which could affect the result of the analysis (Jourdan et al., 2003).
Results from implementing and fostering antimicrobial policy by clinical pharmacist and ID resulted in (37%) reduction in consumption of imipenem and meropenem, which correlate with reduction in antimicrobial resistance and associated costs. Velickovic-Radovanovic et al. (2012) reported a similar result (37.8%) (see Table 1).
Table 2 provides the analysis of antimicrobial use in all wards and captures the prescribing A-443654 cost habits in these wards. Once wards with high consumption rate were identified a more focused approach was done to dictate the use of the antimicrobial under study to verify rational use of the drug and minimize prolonged unnecessary use of the antimicrobial. For example, the ICU was consuming the highest amount of all three antimicrobials. The open structure of ICU ward allows a higher consumption of antimicrobials with less control to antibiotic prescription (Murunga et al., 2005). This pattern is of concern as the ICU is associated with increased emergence of resistance to treated organisms (Fish et al., 1995). In the first period, major sites of prolonged therapy were: medical ward for all three antimicrobials, CCU for caspofungin, and the cardiac ward for meropenem. In the second period, prolonged therapy peaked in: specialized surgery consumption for caspofungin and meropenem, hematology, ICU, and medical for imipenem, and Oncology for meropenem. The third period showed prolonged therapy in: ICU using caspofungin, hematology, ICU, and medical ward using imipenem, and CSICU using meropenem. In the last period prolonged therapy was in: cardiac ward with caspofungin and meropenem, hematology with imipenem, and specialized surgery with meropenem.