Hostname: page-component-78c5997874-fbnjt Total loading time: 0 Render date: 2024-11-13T01:05:38.424Z Has data issue: false hasContentIssue false
  • English
  • Français

A Pilot Study of Antibiotic Cycling in the Community Hospital Setting

Published online by Cambridge University Press:  21 June 2016

Lou Ann Bruno-Murtha ,
John Brusch ,
David Bor ,
Wenjun Li  and
Deborah Zucker
Lou Ann Bruno-Murtha*
Affiliation:
Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
John Brusch
Affiliation:
Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
David Bor
Affiliation:
Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts
Wenjun Li
Affiliation:
Tufts-New England Medical Center, Boston, Massachusetts
Deborah Zucker
Affiliation:
Tufts-New England Medical Center, Boston, Massachusetts
*
DO, 230 Highland Ave., Somerville MA 02143infgerm@aol.com
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To assess the feasibility of a quarterly antibiotic cycling program at two community hospitals and to evaluate its safety and impact on antibiotic use, expenditures, and resistance.

Design:

Nonrandomized, longitudinal cohort study.

Setting:

Two community hospitals, one teaching and one non-teaching.

Patients:

Adult medical and surgical inpatients requiring empiric antibiotic therapy.

Intervention:

We developed and implemented a treatment protocol for the empiric therapy of common infections. Between July 2000 and June 2002, antibiotics were cycled quarterly; quinolones, beta-lactam–inhibitor combinations, and cephalosporins were used. Protocol adherence, adverse drug events, nosocomial infections, antibiotic use and expenditures, resistance among clinical isolates, and length of stay were assessed during eight quarters.

Results:

Physicians adhered to the protocol for more than 96% of 2,494 eligible patients. No increases in nosocomial infections or adverse drug events were attributed to the cycling protocol. Antibiotic acquisition costs increased 31%; there was a 14.7% increase in antibiotic use. Length of stay declined by 1 day. Quarterly variability in the prevalence of vancomycin-resistant enterococci and ceftazidime resistance among combined gram-negative organisms were noted.

Conclusions:

Implementation of an antibiotic cycling program is feasible in a community hospital setting. No adverse safety concerns were identified. Antibiotic cycling was more expensive, partly due to an increase in antibiotic use to optimize initial empiric therapy. Quarterly antibiogram patterns suggested that antibiotic cycling may have impacted resistance, although the small number of isolates precluded statistical analysis. Further assessment of this approach is necessary to determine its relationship to antimicrobial resistance.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 26 , Issue 1 , January 2005 , pp. 81 - 87
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2005

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Gaynes, R. The impact of antimicrobial use on the emergence of antimicrobial-resistant bacteria in hospitals. Infect Dis Clin North Am 1997;11:757–765.Google Scholar
2.American Society of Microbiology. Report of the ASM task force on antimicrobial resistance. Antimicrob Agents Chemother 1995;39(suppl):2–23.Google Scholar
3.Shales, DM, Gerding, DN, John, JF, et al.Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the prevention of antimicrobial resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18:275–291.CrossRefGoogle Scholar
4.Goldmann, DA, Weinstein, RA, Wenzel, RP, et al.Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. JAMA 1996;275:234–240.Google Scholar
5.Centers for Disease Control and Prevention, Food and Drug Administration, National Institutes of Health. Interagency Task Force on Antimicrobial Resistance. Washington, DC: U.S. Department of Health and Human Services; 2001. Available at cdc.gov/drugresistance/actionplan/html/index.htm. Accessed April 2, 2002.Google Scholar
6.White, AC, Atmar, R, Wilson, J, Cate, TR, Stager, CE, Greenburg, SB. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997;25:230–239.CrossRefGoogle ScholarPubMed
7.Frank, MO, Batteiger, BE, Sorensen, SJ, et al.Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clinical Performance and Quality Health Care 1997;5:180–188.Google Scholar
8.Rahal, JJ, Urban, C, Horn, D, et al.Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998;280:1233–1237.Google Scholar
9.Rice, LB, Eckstein, EC, DeVente, J, Shlaes, DM. Ceftazidime-resistant Klebsiella pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical Center. Clin Infect Dis 1996;23:118–124.Google Scholar
10.Meyer, KS, Urban, C, Eagan, JA, Berger, BJ, Rahal, JJ. Nosocomial outbreak of Klebsiella infection resistant to late-generation cephalosporins. Ann Intern Med 1993;119:353–358.Google Scholar
11.Gold, HS, Moellering, RC. Antimicrobial-drug resistance. N Engl J Med 1996;335:1445–1453.CrossRefGoogle ScholarPubMed
12.Seppala, H, Klaukka, T, Vuopio-Varkila, J, et al.The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med 1997;337:441–446.Google Scholar
13.Levy, S, Fitzgerald, G, Macone, A. Changes in intestinal flora of farm personnel after introduction of a tetracycline-supplemented feed on a farm. N Engl J Med 1976;295:583–588.Google Scholar
14.Lipsitch, M, Bergstrom, CT, Levin, BR. The epidemiology of antibiotic resistance in hospitals: paradoxes and prescriptions. Proc Natl Acad Sci USA 2000;97:1938–1943.Google Scholar
15.John, JF Jr. Antibiotic cycling. Infect Control Hosp Epidemiol 2000;21(suppl):S3–S43.Google Scholar
16.Gruson, D, Hilbert, G, Vargas, F, et al.Rotation and restricted use of antibiotics in a medical intensive care unit: impact on the incidence of ventilator-associated pneumonia caused by antibiotic-resistant Gram-negative bacteria. Am J Respir Crit Care Med 2000;162:837–843.Google Scholar
17.Raymond, DP, Pelletier, SJ, Crabtree, TD, et al.Impact of a rotating empiric antibiotic schedule on infectious mortality in an intensive care unit. Crit Care Med 2001;29:1101–1108.Google Scholar
18.Moss, WJ, Beers, MC, Johnson, E, et al.Pilot study of antibiotic cycling in a pediatric intensive care unit. Crit Care Med 2002;30:1877–1882.Google Scholar
19.Fridkin, SK, Hill, HA, Volkova, NV, et al.Temporal changes in prevalence of antimicrobial resistance in 23 U.S. hospitals. Emerg Infect Dis 2002;8:697–701.Google Scholar
20.Fridkin, SK, Steward, CD, Edwards, JR, et al.Surveillance of antimicrobial use and antimicrobial resistance in U.S. hospitals: project ICARE phase 2. Clin Infect Dis 1999;29:245–252.Google Scholar
21.Dominquez, EA, Smith, TL, Reed, E, Sanders, CC, Sanders, WE. A pilot study of antibiotic cycling in a hematology-oncology unit. Infect Control Hosp Epidemiol 2000;21(suppl):S4–S8.Google Scholar
22.Maranan, MC, Moreira, B, Boyle-Vavra, S, Daum, RS. Antimicrobial resistance in staphylococci. Infect Dis Clin North Am 1997;11:813–849.Google Scholar
23.Livermore, DM. Bacterial resistance: origins, epidemiology, and impact. Clin Infect Dis 2003;36(suppl 1):S11–S23.CrossRefGoogle ScholarPubMed
24.Fridkin, SK, Edwards, JR, Tenover, FC, Gaynes, RP, McGowan, JE, for the ICARE project and NNIS system hospitals. Antimicrobial resistance prevalence rates in hospital antibiograms reflect prevalence rates among pathogens associated with hospital-acquired infections. Clin Infect Dis 2001;33:324–330.Google Scholar
25.Centers for Disease Control and Prevention. Centers for Disease Control and Prevention's Campaign to Prevent Antimicrobial Resistance. Atlanta, GA: Centers for Disease Control and Prevention; 2002. Available at www.cdc.gov/drugresistance/healthcare/ha/HASlideSet.pdf. Accessed April 30, 2003.Google Scholar
26.Lister, PD, Gardner, VM, Sanders, CC. Clavulanate induces expression of the Pseudomonas aeruginosa AmpC cephalosporinase at physiologically relevant concentration and antagonizes the antibacterial activity of ticarcillin. Antimicrobial Agents Chemother 1999;43:882–889.Google Scholar
27.Lautenbach, E. Impact of changes in antibiotic use practices on nosocomial infections and antimicrobial resistance: Clostridium difficile and vancomycin-resistant enterococcus (VRE). AHRQ Report 2001;14:144–151.Google Scholar
28.Bradley, SJ, Wilson, ALT, Allen, MC, Sher, HA, Goldstone, AH, Scott, GM. The control of hyperendemic glycopeptide-resistant Enterococcus spp. on a haematology unit by changing antibiotic usage. J Antimicrob Chemother 1999;43:261–265.Google Scholar
29.Quale, J, Landman, D, Guillermo, S, Atwood, E, DiTore, V, Patel, K. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci. Clin Infect Dis 1996;23:1010–1020.Google Scholar