JAC Advance Access originally published online on March 24, 2006
Journal of Antimicrobial Chemotherapy 2006 57(6):1197-1204; doi:10.1093/jac/dkl097
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Antimicrobial practice |
Impact of diversity of antibiotic use on the development of antimicrobial resistance
1 Critical Care Department, Joan XXIII University Hospital, University Rovira i Virgili/Institut Pere Virgili Tarragona 43007, Spain 2 Pharmacy Department, Joan XXIII University Hospital, University Rovira i Virgili/Institut Pere Virgili Tarragona 43007, Spain 3 Epidemiology Department, Joan XXIII University Hospital, University Rovira i Virgili/Institut Pere Virgili Tarragona 43007, Spain 4 Catalan Health Department Lleida 25005, Spain
Received 4 November 2005; returned 25 January 2006; revised 21 February 2006; accepted 1 March 2006
*Corresponding author. Tel: +34-977295818; Fax: +34-977295878; E-mail: asandiumenge{at}yahoo.com
Objectives: To evaluate the impact of different antibiotic strategies on acquisition of resistant microorganisms.
Methods: A prospective study was conducted over a 44 month period in a single ICU. Four empirical antibiotic strategies for ventilator-associated pneumonia (VAP) were sequentially implemented. Over the initial 10 months, patient-specific antibiotic therapy was prescribed; then, 4 month periods of prioritization or restriction rotation cycles of various antimicrobial agents were implemented for a total of 24 months; and, finally, during the last 10 months (mixing period) the first-line antibiotic for VAP was changed following a pre-established schedule to ensure maximum heterogeneity. Antibiotic consumption was closely monitored every month, and antimicrobial resistance patterns were regularly assessed. Antimicrobial heterogeneity was estimated using a modified Peterson index (AHI) measuring the ratios for the five most used antibiotics. Colonization by targeted microorganisms and susceptibility patterns were compared with the patient-specific period.
Results: Higher diversity of antibiotic prescription was obtained during patient-specific therapy (AHI = 0.93) or mixing periods (AHI = 0.95) than during prioritization (AHI = 0.70) or restriction periods (AHI = 0.68). High homogeneity was associated with increases in carbapenem-resistant Acinetobacter baumannii (CR-Ab) [relative risk (RR) 15.5; 95%CI 5.5–42.8], extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae (RR 4.2; 95%CI 1.9–9.3) and Enterococcus faecalis (RR 1.7; 95%CI 1.1–2.9). During the restriction period, incidence of ESBL-producing Enterobacteriaceae and E. faecalis returned to patient-specific rates but CR-Ab remained higher.
Conclusions: Antibiotic prescription patterns balancing the use of different antimicrobials should be promoted to reduce the selection pressure that aids the development of resistance.
Keywords: antibiotic heterogeneity , ventilator-associated pneumonia , antibiotic rotation , cycling antibiotics , antimicrobial mixing
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