1420
Rachael A. Lee et al
Fig. 1. Total average days of therapy per 1,000 patient days of major classes of antibiotics. Beta-lactamase inhibitors include ampicillin/sulbactam, piperacillin-tazobactam, and ticarcillin-clavulanate.
retrospective, quasi-experimental analysis of FQ susceptibility among 5 common hospital isolates: Acinetobacter species, Enter- obacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. We included clinical isolates from all body sites, including blood, skin or soft tissue, respiratory tract, urinary tract, and sterile cultures from the clinical microbiology laboratory from inpatient and emergency department locations. Any organism with the same susceptibility pattern from the same patient was only included once per calendar year. The minimum inhibitory concentration (MIC) for each isolate was determined by Microscan (Beckman Coulter, Carlsbad, CA). Susceptibility breakpoints were determined using MicroscanMIC breakpoints in accordance with US Clinical and Laboratory Standards Institute (CLSI) guidelines. Volume of antimicrobial use is reported in days of FQ therapy per 1,000 patient days.
Antibiotic restriction program
In October 2005, as recommended by the ASP, the Pharmacy and Therapeutics Committee at UAB Hospital instituted a restriction policy requiring prior authorization for FQ. As part of this policy, our antimicrobial inpatient formulary was first streamlined from levofloxacin, gatifloxacin, moxifloxacin, and ciprofloxacin to moxifloxacin and ciprofloxacin as the only FQs available. All inpatient providers were required to obtain ASP approval for empiric use of an FQ (with the exception of moxifloxacin for use for community-acquired pneumonia). Fluoroquinolone use was permitted for treating gram-negative infections if culture results were available and the bacterial isolate was susceptible to an FQ. Prior to the availability of computer physician order entry (CPOE; 2008), FQ prescriptions were manually reviewed by clinical pharmacists. After implementation of CPOE, providers were required to document reason for the use of FQ or to document approval by the ASP ID attending physician. Any data point prior to January 1, 2006 was considered to have occurred during the preintervention period, and any data point after was considered to have occurred during the postintervention period.
Statistical analysis
To determine whether the annual trends in susceptibility were different in the periods prior to and following
Results Fluoroquinolone use
Inpatient FQ use steadily increased from 1998 to 2004 and peaked at 173 days of therapy (DOT) per 1,000 patient days in 2004 (Fig. 1). Following the implementation of the FQ restriction program in October 2005, there was a precipitous drop in FQ use from 2006 to 2007: usage declined from 141 to 52 DOT per 1,000 patient days. From 2007 and continuing through 2016, the rate of FQ use remained below 60 DOT per 1,000 patient days. The lowest period of use was in 2016, with 36 DOT 1,000 patient days. The FQ restriction policy resulted in a decrease in FQ use with a subsequent increase in third- and fourth-generation cephalosporin use. The average number of positive cultures of the 5 total isolates studied increased from 2,615 per year before the policy was imple- mented to 3,226 per year after the policy was implemented. However, a net total decrease was observed for all common parenteral anti–gram-negative antimicrobials, including β-lactamase inhibitors such as piperacillin-tazobactam and ampicillin or sulbactam, cephalosporins, aminoglycosides, and carbapenems. Fig. 2
implementation of the stewardship program (ie, 1998–2005 vs 2006–2016), a Poisson regression including an interaction between time period and continuous time was used to estimate rate ratios (RRs) and associated 95% confidence intervals (CIs) for the annual rate of change in susceptibility for each of the 2 time periods. A likelihood ratio test of the interaction between period and continuous year was used to examine whether the slopes of the annual rate of change in suscept- ibility differed statistically between periods. Poisson models were created for overall susceptibility as well as species-specific susceptibility. All Poisson models accounted for dispersion utilizing a dispersion parametercalculatedasthe division of the model deviance by degrees of freedom. For all analyses, P < .05 was considered statistically significant, and SAS version 9.4 software (SAS Institute, Cary, NC) was used for all analyses.
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