Active Ingredients: Ciprofloxacin
Her anterior fontanelle was full but not bulging. The rest of the systemic examination was unremarkable.
A diagnosis of neonatal sepsis was made, and she was started empirically on intravenous benzylpenicillin and gentamicin. The benzylpenicillin was stopped, and the gentamicin was continued. The baby had a complex inpatient stay, requiring intensive care admission for sepsis with respiratory distress.
She received one dose of intravenous immunoglobulin for severe sepsis and required platelet support.
Five days into her admission, intravenous ciprofloxacin and metronidazole were added to her cefotaxime treatment for suspected necrotizing enterocolitis. She made good progress thereafter.
Repeat CSF and blood cultures were negative. Initial hearing assessments carried out soon after discharge were normal. Unfortunately, 12 weeks later, the baby developed postmeningitic hydrocephalus, which required insertion of a neurosurgical shunt.
This allowed clinicians time to discuss the options available and clearly define the areas where oral ciprofloxacin was recommended and iv ciprofloxacin was acceptable.
The results of the discussion were distilled into a factsheet and distributed to all medical staff. It is likely that both the educational and restrictive components were needed to produce sustained change. Use decreased most significantly following the first components of the programme and there was little extra improvement when restriction was introduced.
However, as the effect of any education is often short-lived, 4 restriction and justification were used to ensure that old prescribing practices did not recur once staff changed. The need for justification every time iv ciprofloxacin was requested served to continually reinforce the policy and its rationale.
This is particularly important for junior medical staff who move frequently between hospitals with different antibiotic recommendations.
Although the use of iv ciprofloxacin was easily monitored following implementation of the programme, it was much more difficult to assess whether there were any harmful consequences. We could not study differences in patient outcome or length of treatment as there is no way to define which patients would have received iv ciprofloxacin had it not been for the change in policy.
Furthermore, the time period was too short to monitor any effect on antimicrobial resistance. The effect on expenditure on some uncontrolled antibiotics was recorded in order to assess whether prescribing had moved rather than decreased.
It is likely that other antibiotics were used to replace ciprofloxacin to a certain extent but it is not possible to say whether there was an actual reduction in antibacterial use.