Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center

BMC Infectious Diseases

Winfried V Kern³  Katja de With¹  Martin Hug²  Hartmut Bertz³  Hansjörg Busch³  Annette Geibel-Zehender³  Werner Vach⁴  Michaela Steib-Bauert³  Klaus Kaier⁴  Johannes P Borde³ 

[1] Present address: Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, D-01307 Dresden, Germany;Pharmacy Service, University Medical Center, D-79106 Freiburg i.Br, Germany;Department of Medicine, Abteilung Infektiologie, Universitätsklinikum Freiburg, Hugstetter Straße 55, D-79106 Freiburg i.Br, Germany;Institute of Medical Biometry and Informatics, Freiburg i.Br, Germany

关键词: Fluoroquinolones;    Cephalosporins;    Interrupted time-series analysis;    Antibiotic stewardship;   

Others  :  1134124
DOI  :  10.1186/1471-2334-14-201

 received in 2014-01-05, accepted in 2014-04-09,  发布年份 2014

【 摘 要 】

Background

Restricted use of third-generation cephalosporins and fluoroquinolones has been linked to a reduced incidence of hospital-acquired infections with multidrug-resistant bacteria. We implemented an intensified antibiotic stewardship (ABS) programme in the medical service of a university hospital center aiming at a reduction by at least 30% in the use of these two drug classes.

Methods

The ABS programme was focused on the 300-bed medical service. Prescription of third-generation cephalosporins was discouraged, whereas the use of penicillins was encouraged. Monthly drug use density was measured in WHO-ATC defined and locally recommended daily doses (DDD and RDD) per 100 patient days, to evaluate trends before (01/2008 to 10/2011) and after starting the intervention (1/2012 to 3/2013). The effect was analysed using interrupted time-series analysis with six non-intervention departments as controls.

Results

Following initiation of the ABS intervention, overall antibiotic use in the medical service declined (p < 0.001). There was a significant intervention-related decrease in the use of cephalosporins and fluoroquinolones (p < 0.001) outperforming the decreasing baseline trend. Trend changes observed in some of the control departments were smaller, and the difference between trend changes in the medical service and those in control departments were highly significant for overall use and cephalosporin use reductions (p < 0.001) as well as for the increasing use of penicillins (p < 0.001). Mean use density levels (in RDD per 100 patient days) dropped for cephalosporins from 16.3 to 10.3 (−37%) and for fluoroquinolones from 17.7 to 10.1 (−43%), respectively. During the same period, the use of penicillins increased (15.4 to 18.2; 18%). The changes in expenditures for antibiotics in the medical service compared to control services minus programme costs indicated initial net cost savings likely to be associated with the programme.

Conclusion

An intensified ABS programme targeting cephalosporin und fluoroquinolone use in the setting of a large academic hospital is feasible and effective. The intervention may serve as a model for other services and hospitals with a similar structure and baseline situation.

【 授权许可】

   
2014 Borde et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM: Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007, 44:159-177.
• [2]Tamma PD, Cosgrove SE: Antimicrobial stewardship. Infect Dis Clin N Am 2011, 25:245-260.
• [3]Young EJ, Sewell CM, Koza MA, Clarridge JE: Antibiotic resistance patterns during aminoglycoside restriction. Am J Med Sci 1985, 290:223-227.
• [4]Monnet DL, MacKenzie FM, López-Lozano JM, Beyaert A, Camacho M, Wilson R, Stuart D, Gould IM: Antimicrobial drug use and methicillin-resistant Staphylococcus aureus, Aberdeen, 1996–2000. Emerg Infect Dis 2004, 10:1432-1441.
• [5]Gerding DN: Antimicrobial cycling: lessons learned from the aminoglycoside experience. Infect Control Hosp Epidemiol 2000, 21:S12-S17.
• [6]Kaier K: Economic implications of the dynamic relationship between antibiotic use and hospital-acquired infections. Value Health 2012, 15:87-93.
• [7]Dancer SJ, Kirkpatrick P, Corcoran DS, Christison F, Farmer D, Robertson C: Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum β-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus. Int J Antimicrob Agents 2013, 41:137-142.
• [8]Livermore DM, Hope R, Reynolds R, Blackburn R, Johnson AP, Woodford N: Declining cephalosporin and fluoroquinolone non-susceptibility among bloodstream Enterobacteriaceae from the UK: links to prescribing change? The Journal of antimicrobial chemotherapy. 2013.
• [9]Kaier K, Hagist C, Frank U, Conrad A, Meyer E: Two time-series analyses of the impact of antibiotic consumption and alcohol-based hand disinfection on the incidences of nosocomial methicillin-resistant Staphylococcus aureus infection and Clostridium difficile infection. Infect Control Hosp Epidemiol 2009, 30:346-353.
• [10]Pépin J, Saheb N, Coulombe MA, Alary ME, Corriveau MP, Authier S, Leblanc M, Rivard G, Bettez M, Primeau V, Nguyen M, Jacob CE, Lanthier L: Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005, 41:1254-1260.
• [11]Aldeyab MA, Harbarth S, Vernaz N, Kearney MP, Scott MG, Darwish Elhajji FW, Aldiab MA, McElnay JC: An evaluation of the impact of antibiotic stewardship on reducing the use of high-risk antibiotics and its effect on the incidence of Clostridium difficile infection in hospital settings. J Antimicrob Chemother 2012, 67:2988-2996.
• [12]Talpaert MJ, Gopal Rao G, Cooper BS, Wade P: Impact of guidelines and enhanced antibiotic stewardship on reducing broad-spectrum antibiotic usage and its effect on incidence of Clostridium difficile infection. J Antimicrob Chemother 2011, 66:2168-2174.
• [13]Lafaurie M, Porcher R, Donay J-L, Touratier S, Molina J-M: Reduction of fluoroquinolone use is associated with a decrease in methicillin-resistant Staphylococcus aureus and fluoroquinolone-resistant Pseudomonas aeruginosa isolation rates: a 10 year study. J Antimicrob Chemother 2012, 67:1010-1015.
• [14]Aldeyab MA, Monnet DL, López-Lozano JM, Hughes CM, Scott MG, Kearney MP, Magee FA, McElnay JC: Modelling the impact of antibiotic use and infection control practices on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus: a time-series analysis. J Antimicrob Chemother 2008, 62:593-600.
• [15]LeBlanc L, Pépin J, Toulouse K, Ouellette MF, Coulombe MA, Corriveau MP, Alary ME: Fluoroquinolones and risk for methicillin-resistant Staphylococcus aureus, Canada. Emerg Infect Dis 2006, 12:1398-1405.
• [16]Petrikkos G, Markogiannakis A, Papaparaskevas J, Daikos GL, Stefanakos G, Zissis NP, Avlamis A: Differences in the changes in resistance patterns to third- and fourth-generation cephalosporins and piperacillin/tazobactam among Klebsiella pneumoniae and Escherichia coli clinical isolates following a restriction policy in a Greek tertiary care hospital. Int J Antimicrob Agents 2007, 29:34-38.
• [17]Aldeyab MA, Harbarth S, Vernaz N, Kearney MP, Scott MG, Darwish Elhajji FW, Aldiab MA, McElnay JC: The impact of antibiotic use on the incidence and resistance pattern of extended-spectrum beta-lactamase-producing bacteria in primary and secondary healthcare settings. Br J Clin Pharmacol 2012, 74:171-179.
• [18]Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN: Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol 2012, 33:338-345.
• [19]Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M: Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013, 19(4):CD003543.
• [20]Hansen S, Sohr D, Piening B, Pena Diaz L, Gropmann A, Leistner R, Meyer E, Gastmeier P, Behnke M: Antibiotic usage in German hospitals: results of the second national prevalence study. J Antimicrob Chemother 2013, 68(12):2934-2939.
• [21]Ansari F, Molana H, Goossens H, Davey P, ESAC II Hospital Care Study Group: Development of standardized methods for analysis of changes in antibacterial use in hospitals from 18 European countries: the European Surveillance of Antimicrobial Consumption (ESAC) longitudinal survey, 2000–06. J Antimicrob Chemother 2010, 65(12):2685-2691.
• [22]Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen P: Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2005, 19(4):CD003543.
• [23]Kern WV, De With K: Rationale Antibiotikaverordnung - Mehr Herausforderungen als Erfolge. Bundesgesundheitsbl 2012, 55:1418-1426.
• [24]Kern WV, Steib-Bauert M, Pritzkow A, Peyerl-Hoffmann G, von Baum H, Frank U, Dettenkofer M, Schneider C, de With K, Bertz H: Fluoroquinolone prophylaxis in haematology-oncology patients – is it still useful? Abstracts of the 19th European Congress of Clinical Microbiology and Infectious Diseases, Helsinki, Finland 2009. Abstract O299
• [25]De With K, Kern WV, Meyer E: Antibiotikaverbrauch im Krankenhaus. In GERMAP2010 Antibiotika-Resistenz und -Verbrauch. Edited by BVL, PEG. Rheinbach: Antiinfectives Intelligence; 2011:17-21.
• [26]Aldeyab MA, Monnet DL, López-Lozano JM, Hughes CM, Scott MG, Kearney MP, Magee FA, McElnay JC: The impact of antimicrobial drug consumption and alcohol-based hand rub use on the emergence and spread of extended-spectrum beta-lactamase-producing strains: a time-series analysis. J Antimicrob Chemother 2009, 63:609-614.
• [27]Medina Presentado JC, Paciel López D, Berro Castiglioni M, Gerez J: Ceftriaxone and ciprofloxacin restriction in an intensive care unit: less incidence of Acinetobacter spp. and improved susceptibility of Pseudomonas aeruginosa. Rev Panam Salud Publica 2011, 30:603-609.