JAC Advance Access published online on March 24, 2006
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkl097
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1 Critical Care Department, Joan XXIII University Hospital, University Rovira i Virgili/Institut Pere Virgili, Tarragona 43007, Spain
* To whom correspondence should be addressed. 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 Conclusions: Antibiotic prescription patterns balancing the use of different antimicrobials should be promoted to reduce the selection pressure that aids the development of resistance.
Received November 4, 2005
Revised February 21, 2006
Accepted March 1, 2006
Antimicrobial practice
Impact of diversity of antibiotic use on the development of antimicrobial resistance
Alberto Sandiumenge 1 *,
Emili Diaz 1,
Alejandro Rodriguez 1,
Loreto Vidaur 1,
Laura Canadell 2,
Montserrat Olona 3,
Montserrat Rue 4,
and
Jordi Rello 1
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
Alberto Sandiumenge, E-mail: asandiumenge{at}yahoo.com
Abstract 
-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.
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