Hospital-wide formulary conversion and implementation of extended infusion cefepime

Service or Program:

A multidisciplinary team was formed to address the switching of formulary 3^rd-generation cephalosporin (ceftazidime to cefepime) and the feasibility of converting from the standard 30-minute infusion to an extended infusion of cefepime. On the day of hospitalwide conversion, the orderables for cefepime were reprogrammed in the computerized prescriber-order-entry system to allow separate options for the 30-minute infusion (for pediatric and emergency room patients) and the extended-infusion regimen. A splash screen reminding prescribers of the formulary change and extended infusion was instituted and smart pump drug libraries were also modified to default to the 4 hour extended infusion rate.

Justification/Documentation:

The most recent (2013-14) antibiogram from our institution shows that cefepime has better in vitro activity against selected Enterobacteriacae such as Enterobacter species, and similar in vitro activity against P. aeruginosa, E. coli, and K. pneumonia compared to ceftazidime. Like other beta-lactams, cefepime displays time-dependent bactericidal activity which is enhanced when each dose is administered as an extended (i.e., 4 hour) infusion. The development and implementation of an extended-infusion cefepime program may be associated with lower mortality compared to a standard 30 minute infusion based on a 2013 quasi-experimental study of the treatment of Pseudomonas infection.

Transferability:

With the use of computer generated default order sentences, informational splash screen alerts, and use of smart pump drug libraries, the transition to an extended infusion medication program can be seamlessly rolled out leading to potentially better patient outcomes.

Impact:

A hospitalwide program for the administration of extended-infusion cefepime was safely and successfully implemented using a multi-disciplinary approach in an urban teaching hospital, leading to broader coverage against susceptible aerobic gram-negative bacilli including Enterobacter species and P. aeruginosa and possible better patient outcomes.