Infection Control & Hospital Epidemiology (2018), 39, 1419–1424 doi:10.1017/ice.2018.245
Original Article
Improvement of gram-negative susceptibility to fluoroquinolones after implementation of a pre-authorization policy for fluoroquinolone use: A decade-long experience
Rachael A. Lee MD1, Morgan C. Scully MD1, Bernard C. Camins MD, MSc1, Russell L. Griffin PhD2, Danielle F. Kunz RPh, BCPS (AQ)-ID3, Stephen A. Moser PhD4, Craig J. Hoesley MD1, Todd P. McCarty MD1
and Peter G. Pappas MD1 1Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, 2Department of Epidemiology, University of Alabama School of Public Health, Birmingham, Alabama, 3Infectious Disease Solutions for Antimicrobial Stewardship, LLC, Birmingham, Alabama, and 4Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
Abstract
Objective: Due to concerns over increasing fluoroquinolone (FQ) resistance among gram-negative organisms, our stewardship program implemented a preauthorization use policy. The goal of this study was to assess the relationship between hospital FQuse and antibiotic resistance. Design: Retrospective cohort. Setting: Large academic medical center. Methods: We performed a retrospective analysis of FQ susceptibility of hospital isolates for 5 common gram-negative bacteria: Acinetobacter spp., Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Primary endpoint was the change of FQ susceptibility. A Poisson regression model was used to calculate the rate of change between the preintervention period (1998–2005) and the postimplementation period (2006–2016). Results: Large rates of decline of FQ susceptibility began in 1998, particularly among P. aeruginosa, Acinetobacter spp., and E. cloacae. Our FQ restriction policy improved FQ use from 173 days of therapy (DOT) per 1,000 patient days to <60 DOT per 1,000 patient days. Fluoroquinolone susceptibility increased for Acinetobacter spp. (rate ratio [RR], 1.038; 95% confidence interval [CI], 1.005–1.072), E. cloacae (RR, 1.028; 95% CI, 1.013–1.044), and P. aeruginosa (RR, 1.013; 95%CI, 1.006–1.020). No significant change in susceptibility was detected for K. pneumoniae (RR, 1.002; 95% CI, 0.996–1.008), and the susceptibility for E. coli continued to decline, although the decline was not as steep (RR, 0.981; 95% CI, 0.975–0.987). Conclusions: A stewardship-driven FQ restriction program stopped overall declining FQ susceptibility rates for all species except E. coli. For 3 species (ie, Acinetobacter spp, E. cloacae, and P. aeruginosa), susceptibility rates improved after implementation, and this improvement has been sustained over a 10-year period.
(Received 29 May 2018; accepted 30 August 2018; electronically published October 9, 2018)
Due to their broad-spectrum antimicrobial coverage through a novel mechanism, relative safety, and ease of delivery, fluor- oquinolone (FQ) use in the United States has increased expo- nentially since its introduction in the 1980s.1,2 With widespread use both in the inpatient and outpatient settings, resistance among gram-negative pathogens to this class of antibiotics has also increased. A recent analysis of FQ resistance rates among Escherichia coli urinary isolates in the United States found rates consistently above 25% and up to 40% in some regions.3,4 Prior FQ use has been identified in multiple studies as a risk factor for resistant infection.5–10 Additionally, invasive infection with FQ- resistant bacteria is associated with increased mortality.9
Authors for correspondence: Rachael A. Lee, MD, 1900 University Boulevard, THT
216, Birmingham, AL 35294. E-mail:
ralee@uabmc.edu. Also,MorganC. Scully,MD,1900 University Boulevard, THT 229, Birmingham, AL 35294. E-mail:
morganscully@uabmc.edu
Cite this article: Lee RA, et al. (2018). Improvement of gram-negative susceptibility to fluoroquinolones after implementation of a pre-authorization policy for fluoroquinolone use: A decade-long experience. Infection Control & Hospital Epidemiology 2018, 39, 1419–1424. doi: 10.1017/ice.2018.245
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
Methods Design and setting
At the University of Alabama at Birmingham (UAB) Hospital, a 1,157-bed academic tertiary-care center, we performed a
to be effective at improving antimicrobial use in hospitals.11 ASPs vary in their interventions, but they share the same common goals of decreasing inappropriate antimicrobial use, improving resis- tance patterns, and reducing cost.12 A common intervention employed in ASPs is requiring prior authorization before use of certain antimicrobials. A large-scale public health data project from the United Kingdom demonstrated that decreased use of FQ in prescribing practices led to declining resistance rates.13 Therefore, we sought to evaluate the impact of requiring prior authorization for fluoroquinolone prescription on gram-negative bacteria FQ susceptibility rates at an academic medical center.
Antimicrobial stewardship programs (ASPs) have been shown
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