Local Antibiotic Policy Research Articles

Impact d'une politique de prescription d'antibiotiques dans un service de réanimation tunisien

Objective The aim of this study was to assess the efficacy of local antibiotic policy in a Tunisian ICU. The predefined primary efficacy objectives were the decrease of antibiotic consumption, reduction of inappropriate antibiotic (ATB) use and antimicrobial resistance. Design This prospective intervention study lasted from January 2002 to December 2004. In the first study period or the baseline phase (from January to December 2002) we focused on physician education for ATB prescription practice. The second period concerned intervention (control of all ATB use). Results The number of infection episodes significantly decreased from 2002 to 2004; 198 infection episodes in 2002 (1.63 ± 1.15 episodes/patient) versus 124 in 2003 (1.22 ± 0.93) ( P < 0.0008) versus 121 in 2004 (1.23 ± 0.8) (P1 < 0.0008). The number of ATB/prescription also significantly decreased from 1.85 ± 1.3 in 2002 to 1.5 ± 0.9 in 2003 ( P = 0.02) and 1.5 ± 1.4 in 2004 (P1 = 0.05). Appropriateness of antibiotherapy improved during the intervention period: 65% in 2002 versus 86% in 2003 ( P = 0.0003) and 81% in 2004 (P1 = 0.02). The length of antibiotherapy in survivors was considerably reduced: 14.1 ± 2.9 days in 2002 versus 11.9 ± 1.2 days in 2003 ( P < 10 −5) and 10.9 ± 2.5 days in 2004 (P1 < 10 −5) with a significant reduction of antibiotherapy cost and length of stay (20.4 ± 9 days in 2002 versus 18.3 ± 6 days in 2003 and 16.9 ± 8 days in 2004; P = 0.05; P1 = 0.02). There was a significant decrease of carbapenem resistant Enterobacteriaceae esβ, Pseudomonas aeruginosa and Acinetobacter baumannii.

Antibiotic use is associated with resistance of environmental organisms in a teaching hospital

An intensive care unit (ICU), acute stroke unit (ASU) and medical day bed unit (MDBU) underwent a standardized four-month environmental screening programme. The aim was to examine environmental organisms from these wards and compare bacterial resistances in association with antimicrobial usage. Hand-touch and other sites were screened using commercial dip-slides, and staff were asked to provide fingertip cultures. Patient blood isolates were retained throughout the study. Organisms were quantitatively and qualitatively assessed including antimicrobial susceptibility testing. Antibiotic consumption data in defined daily doses/1000 patient-days were obtained for each unit for the previous year. Two hundred and seventy-six staphylococci and 67 Gram-negative bacilli were recovered. Antibiotic resistance was significantly associated with individual wards for staphylococci (P<0.0001) and coliforms (P=0.04), and trends were also demonstrated for other Gram-negative organisms (P=0.06) despite fewer numbers. Antibiotic consumption on the ICU was six-fold higher than on the ASU and MDBU. Associations were found between consumption of selected antibiotic groups and corresponding resistances among staphylococci and Gram-negative bacilli. Antibacterial resistance was the only significant difference between environmental bacteria from different wards, and appeared to reflect prescribing pressure. Visual inspection of a ward may not provide a reliable guide regarding the presence of multi-resistant organisms in the hospital environment or the potential risk of infection. These findings have implications for local antibiotic policies, infection control and cleaning schedules.

PGI14: HOW IMPORTANT IS APPROPRIATE EMPIRICAL ANTIBIOTIC TREATMENT FOR INTRA-ABDOMINAL INFECTIONS?

OBJECTIVES: To assess the association between hospital costs and the appropriateness of empirical antibiotic treatment for community-acquired intra-abdominal infection. METHODS: Patients were identified from hospital discharges from three hospitals for 1993 to 1997. Medical records were obtained to validate the diagnosis and obtain details of antibiotic therapy and its outcome. Valid cases had macroscopic evidence of intra-abdominal infection at operation, therefore all cases had surgical control of infection in addition to antimicrobial therapy. Appropriateness of empirical therapy was assessed from the results of in-vitro sensitivity tests (culture positive cases) and compliance with local antibiotic policies (culture negative cases). RESULTS: We identified 294 valid cases of intra-abdominal infection of whom 162 (55%) were culture positive. Appropriate antibiotic treatment was associated with significantly shorter length of stay and lower investigation costs for patients with positive cultures but not for patients with negative cultures or no test/result (data not shown). Culture +ve cases, appropriate (n = 129) vs inappropriate (n = 33): mean length of stay 12 vs 22 days, p = 0.0007 boot strap t test, mean investigation cost £250 vs £409 p = 0.04, mean antibiotic cost £138 vs £128 p = 0.9. A log transformed linear regression analysis was carried out on the cost data for the culture positive cases adjusting for five independent variables. Inappropriate antibiotics, increasing age and a higher number of comorbidities and previous admissions were significantly associated with increased cost of hospital stay but not gender. This model accounted for 34% of the variance in cost of hospital stay. For the cost of investigations inappropriate treatment, increasing age and number of comorbidities were all significant predictors accounting for 26% of variance in costs. Number of comorbidities was the only variable significantly associated with the cost of antibiotics. CONCLUSIONS: Appropriate empirical antibiotic treatment of patients with culture positive intra-abdominal infection is strongly associated with length of stay and hospital costs.

National and Local Antibiotic Policies in Central and Eastern Europe

To assess the antibiotic policies of Central European countries, we performed an overview of antibiotic stewardship, prescription habits and antibiotic prescription regulatory procedures. Since most Central European countries have had centralized health care and drug policies, the situation 10 years after decentralization is surprising. Only 3 of 10 Central European countries have some regulation of prescription of antibiotics, only 4 restrict some antibiotics, only 5 have hospital and only 3 national antibiotic policies. In all but 3 countries physicians can prescribe quinolones and/or 3rd generation oral cephalosporins as first-line antibiotics. Information on local and national antibiotic policies in Central and Eastern European countries is given including prescription guidelines for antibiotic use in community and hospital.

A 10 year survey of the antimicrobial susceptibility of urinary tract isolates in the UK: the Microbe Base project.

Microbe Base is a national computerized database comprising in excess of 1.7 million patient records down-loaded from the laboratory computer systems of 61 participating UK laboratories over 10 years. This paper highlights the antimicrobial susceptibilities of organisms isolated from the urinary tract which comprise around 50% of all isolates in the database. These data may be used to determine trends in antimicrobial susceptibilities; to formulate local antibiotic policies; to compare local with national data and, overall, to assist clinicians in the rational choice of antibiotic therapy and to prevent misuse, or overuse, of antibiotics.

Trends in Bacterial Resistance to Fluoroquinolones

The emergence of resistance to fluoroquinolones in virtually all species of bacteria was recognized soon after the introduction of these compounds for clinical use more than 10 years ago. Various resistance mechanisms, often interdependent, may explain different levels of resistance. Epidemiological factors, local antibiotic policies, patients' characteristics, origin of the strains, and geographic location are among the factors contributing to highly variable resistance rates. During the last several years, resistance to fluoroquinolones has remained very high among methicillin-resistant Staphylococcus aureus strains and in intensive care unit patients, and it has increased among nosocomial isolates of Klebsiella pneumoniae, Serratia marcescens, and Pseudomonas aeruginosa. More worrisome are recent reports of an overall increase in resistance to fluoroquinolones among bacteria responsible for community-acquired infections, such as Escherichia coli, Salmonella species, Campylobacter species and Neisseria gonorrhoeae.

Temporal changes in the sensitivity of Neisseria gonorrhoeae to penicillin in Edinburgh, Scotland.

Increased resistance of Neisseria gonorrhoeae to penicillin has been reported from many centres around the world since the introduction of antibiotic therapy in the 1940s. This study reports the temporal changes in gonococcal penicillin sensitivity over a 3-year period. All patients with a diagnosis of gonorrhoea in the city of Edinburgh, Scotland between 1990 and 1992 were included in the study. Penicillin sensitivity of isolates was analysed in relation to the sex and sexual orientation of the patient and the antibiotic therapy given. Four hundred and twenty-seven new patient episodes of infection occurred of which penicillin sensitivities were available in 426. Eleven episodes of PPNG infection occurred. Chromosomally mediated penicillin resistance did not increase over the study period. No differences were evident in the sensitivity of isolates from homosexual and heterosexual patients. Unlike many other areas the relative resistance of N. gonorrhoeae is not increasing in Edinburgh at present. This may relate to local antibiotic policies combined with intrinsic characteristics of N. gonorrhoeae itself. Unlike previous reports there did not appear to be any increased resistance to penicillin in isolates from gay men.

The epidemiology of bacterial resistance to quinolones.

The new fluoroquinolones have been in use for nearly 10 years in the treatment of community- and nosocomially-acquired infections. Resistant clones may be selected during therapy and disseminate if favourable epidemiological conditions prevail. Resistance to the fluoroquinolones is still rare in common pathogens with 97 to 100% of strains remaining susceptible. Resistance has been reported in methicillin-susceptible Staphylococcus aureus, Campylobacter jejuni/coli, Salmonella, Shigella and Escherichia coli. Among nosocomial pathogens, the incidence of fluoroquinolone resistance varies between bacterial species, countries and periods of study, and is dependent on local epidemiological factors and antibiotic policies. The highest incidence of resistance is observed in Serratia and Acinetobacter spp., and particularly in methicillin-resistant S. aureus. Surveillance programmes are needed to follow up trends in resistance to the fluoroquinolones and their possible association with clinical failures.

Epidemiology of fecal strains of the family Enterobacteriaceae in 22 neonatal wards and influence of antibiotic policy.

The gram-negative fecal floras from 953 infants were studied upon discharge of the infants from 22 neonatal wards. More than 600 distinct phenotypes of Escherichia coli, Klebsiella spp., and Enterobacter spp. were distinguished by high-resolution biotyping. The colonization patterns observed showed considerable local and temporal variation. The major (M) strains (phenotypes), which colonized more than 10% and up to 78% of the infants in a ward (median, 23%), were Klebsiella oxytoca (15 strains), E. coli (4 strains), Klebsiella pneumoniae (1 strain), and Enterobacter cloacae (1 strain). Resistance to beta-lactam antibiotics was more pronounced among M strains than among strains of enteric bacteria colonizing few or single infants only. Local antibiotic policy influenced the colonization patterns. Despite the fact that M strains of Klebsiella spp. were usually resistant to ampicillin as well as to cephalexin and cefuroxime, their local dissemination was associated with the use of ampicillin with or without gentamicin but not with the use of cefuroxime. It thus appeared that in the neonatal setting, ampicillin posed a greater risk of local spread of certain drug-resistant bacterial clones than a newer cephalosporin, such as cefuroxime.

Surveillance of aminoglycoside resistance: European data

The susceptibility patterns of gram-negative aerobic organisms to aminoglycosides differ widely from one European health care center to another and depend upon local antibiotic prescribing policies. Reports of the susceptibility of Pseudomonas aeruginosa to gentamicin and tobramycin have ranged from as low as 49.8 percent and 77.7 percent, respectively, in Greece, to as high as 96.6 percent and 99.2 percent, respectively, in the United Kingdom. The susceptibility of P. aeruginosa to gentamicin, tobramycin, and amikacin decreased in our hospital from 73.1 percent, 94.8 percent, and 95.6 percent, respectively, in 1982, to 43.1 percent, 70.6 percent, and 74.3 percent, respectively, in 1984. A prospective surveillance study of the susceptibility of gram-negative aerobic bacilli to four aminoglycosides (gentamicin, tobramycin, amikacin, and netilmicin) was performed over a period of 17 months. Gentamicin and tobramycin were freely used, while the use of amikacin was restricted throughout the hospital during a four-month baseline period (May through August 1984). Gentamicin and tobramycin accounted for 94 percent of the aminoglycoside use. During the following 13 months (September 1984 through September 1985), amikacin was used as the first-line aminoglycoside and accounted for more than 97 percent of the aminoglycoside usage. A total of 1,866 organisms were analyzed during the baseline period; 5,429 were analyzed during the amikacin-usage period. The overall susceptibility to gentamicin, tobramycin, amikacin, and netilmicin increased from 86.9 percent, 90.4 percent, 94.2 percent, and 88.3 percent, respectively, to 92.3 percent, 94.0 percent, 97.3 percent, and 92.3 percent, respectively. P. aeruginosa isolates had the most striking changes, with the susceptibility to gentamicin, tobramycin, amikacin, and netilmicin increasing from 43.1 percent, 70.6 percent, 74.3 percent, and 50.6 percent, respectively, during the baseline period, to 64.5 percent, 81.6 percent, 90.8 percent, and 65.1 percent, respectively, during the amikacin-usage period. The use of amikacin as a first-line aminoglycoside, while use of the other aminoglycosides was restricted, seemed to have a favorable influence on the susceptibility pattern of gram-negative aerobic isolates in our hospital.

Laboratory aspects of erythromycin

Generally there appears to be a reasonable correlation between the results of laboratory sensitivity tests to erythromycin and the clinical efficiacy of the drug in treatment, but relative degrees of resistance are not associated with failure in clinical response in upper and lower respiratory tract disease. The same is possibly true for erythromycin in soft tissue infections due to gram-positive bacteria such as staphylococci and streptococci. Thus erythromycin is a useful alternative to penicillin for example, in tonsillitis, and to ampicillin in lower respiratory tract infections such as bronchitis. Further, it has been used successfully in pre-operative preparation of the colon and there is no evidence that it is liable to encourage resistant organisms in the intestinal tract. On this basis erythromycin must be considered a useful additional antibiotic for use in a local antibiotic policy, since the most important factor in such policies is the availability of a wide selection of agents which allows frequent changes of treatment. Erythromycin appears to be particularly useful for this purpose in general practice where a high proportion of infection has been shown to be due to erythromycin-sensitive bacteria. In addition there are particular indications for erythromycin, e. g. in Mycoplasma infections and chronic lesions such as prostatitis where L-forms (protoplasts) may be involved, and also undoubtedly because it is concentrated in the prostatic secretion.