JAC Advance Access originally published online on November 20, 2008
Journal of Antimicrobial Chemotherapy 2009 63(1):224; doi:10.1093/jac/dkn465
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Letter to the Editor |
Comment on: Interventions to control MRSA: high time for time-series analysis?
Department of Medical Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
* Tel: +44-1224-840688; Fax: +44-1224-840632; E-mail: i.m.gould{at}abdn.ac.uk
Keywords: antibiotic stewardship , MRSA , interrupted time-series analysis
I enjoyed Harbarth and Samore's thoughtful leader1 on interventions to control MRSA and agree with their sentiments and recommendations that more well-designed studies are urgently needed and that multiple interventions are most likely to work.
I would like, however, to emphasize that there are many more published intervention studies assessing the effects of antibiotic stewardship on MRSA than they quote, certainly more than the ‘surprisingly few’ that they state.2–12 These studies (and there may be more as I have not performed a systematic review of the literature) consistently (11 of 11) demonstrate reduction in MRSA, usually after reduction in β-lactam and/or quinolone use. Our own work also shows macrolide use to be consistently important in causing increased MRSA rates.13,14
While the Cochrane review15 referred to by Harbarth and Samore did not show any evidence that antibiotic stewardship could reduce MRSA, three of the studies8,9,12 not quoted by them are reasonable quality interrupted time series that have been published since the Cochrane Review. Moreover, the consistency of the findings and the scientific plausibility of all 11 studies counter their uncontrolled nature and add considerable weight to the argument that much more emphasis should be put on antibiotic stewardship to control MRSA, particularly in the face of failure of the current MRSA control strategies.
The real problem is how to initiate and maintain major changes in our antibiotic prescribing habits. Major effort is required to be put into answering the difficult questions surrounding this need. It is not easy to make significant and persistent inroads into a hospital's reliance on β-lactams, quinolones and macrolides, although the advent of widespread MRSA admission screening should make it easier to avoid these antibiotics in patients colonized with MRSA.16,17
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1 Harbarth S, Samore MH. Interventions to control MRSA: high time for time-series analysis? J Antimicrob Chemother (2008) 62:431–3.
2
Fukatsu K, Saito H, Matsuda T, et al. Influences of type and duration of antimicrobial prophylaxis on an outbreak of methicillin-resistant Staphylococcus aureus and on the incidence of wound infection. Arch Surg (1997) 132:1320–5.
3 Frank MO, Batteiger BE, Sorensen SJ, et al. Decrease in expenditure and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clin Perform Qual Health Care (1997) 5:180–8.[Medline]
4 Keegan JM, Rhames T, Boersma B. Development of a strategy for decreasing multi-drug resistant bacteria with implementation of a program emphasizing appropriate antibiotic utilization and strict infection control measures in Western South Dakota. J Med (2002) 55:401–4.
5 Allegranzi B, Luzzati R, Luzzani A, et al. Impact of antibiotic changes in empirical therapy on antimicrobial resistance in intensive care unit-acquired infections. J Hosp Infect (2002) 52:136–4.[CrossRef][Web of Science][Medline]
6 Geisser A, Gerbeaux P, Granier I, et al. Rational use of antibiotics in the intensive care unit: impact on microbial resistance and costs. Intensive Care Med (2003) 29:49–54.[Web of Science][Medline]
7 Aubert G, Carricajo A, Vautrin AC, et al. Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit. J Hosp Infect (2005) 59:83–9.[CrossRef][Web of Science][Medline]
8
Martin C, Ofotokun I, Rapp R, et al. Results of an antimicrobial control program at a university hospital. Am J Health Syst Pharm (2005) 62:732–8.
9 Cook PP, Catrou P, Gooch M. Effect of reduction in ciprofloxacin use on prevalence of methicillin-resistant Staphylococcus aureus rates within individual units of a tertiary care hospital. J Hosp Infect (2006) 64:348–51.[CrossRef][Web of Science][Medline]
10 Avery CME, Ameerally P, Castling B, et al. Infection of surgical wounds in the maxillofacial region and free flap donor sites with methicillin-resistant Staphylococcus aureus. Br J Oral Maxillofac Surg (2006) 44:217–21.[Medline]
11 Bassetti M, Righi E, Molinari MP, et al. Effectiveness of an intervention designed to decrease methicillin-resistant Staphylococcus aureus (MRSA) by limiting cephalosporin use in ICU. In: In Abstracts of the 46th ICAAC San Francisco, CA, 27–30 September 2006. Washington, DC, USA: American Society for Microbiology. Abstract K-1407.
12 Liebowitz LD, Blunt MC. Modification in prescribing practices for third-generation cephalosporins and ciprofloxacin is associated with a reduction in methicillin-resistant Staphylococcus aureus bacteraemia rate. J Hosp Infect (2008) 69:328–36.[Medline]
13 Monnet DL, MacKenzie FM, Lopez-Lozano JM, et al. Antimicrobial drug use and methicillin-resistant Staphylococcus aureus, Aberdeen 1996–2000. Emerg Infect Dis (2004) 10:1432–41.[Web of Science][Medline]
14 Mahamat A, MacKenzie FM, Brooker K, et al. Impact of infection control interventions and antibiotic use on hospital MRSA: a multi-variate interrupted time-series analysis. Int J Antimicrob Agents (2007) 30:169–76.[CrossRef][Web of Science][Medline]
15 Davey P, Brown E, Fenelon L, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev (2005) CD003543.
16
Dancer SJ. The effect of antibiotics on methicillin-resistant Staphylococcus aureus. J Antimicrob Chemother (2008) 61:246–53.
17
Gould IM. Antibiotic policies to control hospital-acquired infection. J Antimicrob Chemother (2008) 61:763–5.
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