JAC Advance Access originally published online on July 31, 2008
Journal of Antimicrobial Chemotherapy 2008 62(5):1165-1166; doi:10.1093/jac/dkn324
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Letters to the Editor |
Control of extended-spectrum β-lactamase-producing Klebsiella pneumoniae by utilizing a computer-assisted management program to restrict third-generation cephalosporin use—authors’ response
1 Division of Infectious Diseases, Korea University Medical Center, Seoul, Republic of Korea 2 Institute of Emerging Infectious Diseases, Korea University, Seoul, Republic of Korea
* Correspondence address. Division of Infectious Diseases, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, 126-1 5-ga, Anam-dong, Sungbuk-gu, Seoul 136-705, Korea. Tel: +82-2-920-5658; Fax: +82-2-920-5616; E-mail: macropha{at}korea.ac.kr
Keywords: intervention , antibacterial agents , bacterial drug resistance , cephalosporins , β-lactamases
We thank Huttner et al.1 for their comments on our paper2 on the control of extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae using a computer-assisted management program to restrict third-generation cephalosporin use.
They mainly comment on several methodological problems in measuring the effect of the intervention in our study, based on the recommendation by the ORION statement.3 We had already tried to interpret our data by using the interrupted time-series analysis with segmental regression analysis.4 However, the level and trend of the third-generation cephalosporin consumption in the pre-intervention segment as a control for the intervention segment did not allow us to evaluate the effects of our intervention adequately. This is probably due to the limited time points of 9 months and delayed effects of our intervention. We have described the limit of our data to fit the interrupted time-series analysis model in our paper.
They also argue that our intervention to restrict the third-generation cephalosporin use is hardly compatible with successful intervention. Although the antibiotic consumption started to increase for the latter 3 months of the intervention period (phase II), we assessed that the significant reduction of the antibiotic use in the intervention period was a result of the intervention intensified by biweekly feedback to doctors and departments. Our study also indicates that the outcome of the intervention to control antibiotic use can be delayed, as previously reported in other studies.5,6 It was apparent that the proportion of ESBL-producing K. pneumoniae began to decrease 6 months after the intensive intervention and then significantly decreased in the following maintenance period, even with returning the antibiotic consumption to the high pre-intervention level. We assume that intensive intervention longer than 9 months would have been better to prove the outcome of the intervention. We would also like to stress that the autonomous computerized intervention program for antibiotic use requires continuous monitoring and feedback to maintain the level of the intervention. As we noted in our paper, the effect of intervention was lost in the following maintenance periods (phase III), probably due to decreased physicians' compliance with the computerized program in the absence of feedback from the peer group.
With regard to their later comments, ESBL-producing K. pneumoniae isolates were not clustered in certain wards and rather showed rapid hospitalwide dissemination in the beginning of the intervention period. As they expected, the ESBL isolates showed cross-resistance to other antibiotics, including ciprofloxacin (84%), aztreonam (98%) and piperacillin/tazobactam (26%). Simultaneous restriction of third-generation cephalosporin and ciprofloxacin use might be more effective strategies, but its clinical application might not be easy because of limited alternative drugs available. Lastly, we did not force or intensify any infection control policy such as contact isolation and strengthening of hand hygiene throughout the study period. We learnt from this experience that control of antibiotic use might be one of the essential components for strategies to control ESBL-producing bacteria.
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None to declare.
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1 Huttner B, Pittet D, Harbarth S. Comment on: Control of extended-spectrum β-lactamase-producing Klebsiella pneumoniae using a computer-assisted management program to restrict third-generation cephalosporin use. J Antimicrob Chemother (2008) 62:1165.
2
Kim JY, Sohn JW, Park DW, et al. Control of extended-spectrum β-lactamase-producing Klebsiella pneumoniae using a computer-assisted management program to restrict third-generation cephalosporin use. J Antimicrob Chemother (2008) 62:416–21.
3
Stone SP, Cooper BS, Kibbler CC, et al. The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection. J Antimicrob Chemother (2007) 59:833–40.
4
Ramsay C, Brown E, Hartman G, et al. Room for improvement: a systematic review of the quality of evaluations of interventions to improve hospital antibiotic prescribing. J Antimicrob Chemother (2003) 52:764–71.
5
Rice LB, Willey SH, Papanicolaou GA, et al. Outbreak of ceftazidime resistance caused by extended-spectrum β-lactamases at a Massachusetts chronic-care facility. Antimicrob Agents Chemother (1990) 34:2193–9.
6
Ma MY, Goldstein EJ, Friedman MH, et al. Resistance of Gram-negative bacilli as related to hospital use of antimicrobial agents. Antimicrob Agents Chemother (1983) 24:347–52.
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