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Laffont-Lozes P, Larcher R, Salipante F, Leguelinel-Blache G, Dunyach-Remy C, Lavigne JP, Sotto A, Loubet P. Usefulness of dynamic regression time series models for studying the relationship between antimicrobial consumption and bacterial antimicrobial resistance in hospitals: a systematic review. Antimicrob Resist Infect Control 2023; 12:100. [PMID: 37697357 PMCID: PMC10496333 DOI: 10.1186/s13756-023-01302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUNG Antimicrobial resistance (AMR) is on the rise worldwide. Tools such as dynamic regression (DR) models can correlate antimicrobial consumption (AMC) with AMR and predict future trends to help implement antimicrobial stewardship programs (ASPs). MAIN BODY We carried out a systematic review of the literature up to 2023/05/31, searching in PubMed, ScienceDirect and Web of Science. We screened 641 articles and finally included 28 studies using a DR model to study the correlation between AMC and AMR at a hospital scale, published in English or French. Country, bacterial species, type of sampling, antimicrobials, study duration and correlations between AMC and AMR were collected. The use of β-lactams was correlated with cephalosporin resistance, especially in Pseudomonas aeruginosa and Enterobacterales. Carbapenem consumption was correlated with carbapenem resistance, particularly in Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii. Fluoroquinolone use was correlated with fluoroquinolone resistance in Gram-negative bacilli and methicillin resistance in Staphylococcus aureus. Multivariate DR models highlited that AMC explained from 19 to 96% of AMR variation, with a lag time between AMC and AMR variation of 2 to 4 months. Few studies have investigated the predictive capacity of DR models, which appear to be limited. CONCLUSION Despite their statistical robustness, DR models are not widely used. They confirmed the important role of fluoroquinolones, cephalosporins and carbapenems in the emergence of AMR. However, further studies are needed to assess their predictive capacity and usefulness for ASPs.
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Affiliation(s)
- Paul Laffont-Lozes
- Department of Pharmacy, Nimes University Hospital, Nimes, France
- Infectious and Tropical Diseases Department, Nimes University Hospital, Nimes, France
| | - Romaric Larcher
- Infectious and Tropical Diseases Department, Nimes University Hospital, Nimes, France.
- PhyMedExp, INSERM U1046, CNRS, University of Montpellier, Montpellier, France.
- Service des Maladies Infectieuses et Tropicales, Hôpital Caremeau - CHU de Nimes, 1 Place Robert Debre, Nîmes, 30000, France.
| | - Florian Salipante
- Department of Biostatistics, Epidemiology, Public Health, and Innovation in Methodology (BESPIM), University of Montpellier, Nîmes University Hospital, Nimes, France
| | - Geraldine Leguelinel-Blache
- Department of Pharmacy, Nimes University Hospital, Nimes, France
- Department of Biostatistics, Epidemiology, Public Health, and Innovation in Methodology (BESPIM), University of Montpellier, Nîmes University Hospital, Nimes, France
| | - Catherine Dunyach-Remy
- Department of Microbiology and Hospital Hygiene, Nimes University Hospital, Nimes, France
- VBIC, INSERM U1047, University of Montpellier, Nimes, France
| | - Jean-Philippe Lavigne
- Department of Microbiology and Hospital Hygiene, Nimes University Hospital, Nimes, France
- VBIC, INSERM U1047, University of Montpellier, Nimes, France
| | - Albert Sotto
- Infectious and Tropical Diseases Department, Nimes University Hospital, Nimes, France
- VBIC, INSERM U1047, University of Montpellier, Nimes, France
| | - Paul Loubet
- Infectious and Tropical Diseases Department, Nimes University Hospital, Nimes, France
- VBIC, INSERM U1047, University of Montpellier, Nimes, France
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Colson AR, Megiddo I, Alvarez-Uria G, Gandra S, Bedford T, Morton A, Cooke RM, Laxminarayan R. Quantifying uncertainty about future antimicrobial resistance: Comparing structured expert judgment and statistical forecasting methods. PLoS One 2019; 14:e0219190. [PMID: 31276536 PMCID: PMC6611586 DOI: 10.1371/journal.pone.0219190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022] Open
Abstract
The increase of multidrug resistance and resistance to last-line antibiotics is a major global public health threat. Although surveillance programs provide useful current and historical information on the scale of the problem, the future emergence and spread of antibiotic resistance is uncertain, and quantifying this uncertainty is crucial for guiding decisions about investment in antibiotics and resistance control strategies. Mathematical and statistical models capable of projecting future rates are challenged by the paucity of data and the complexity of the emergence and spread of resistance, but experts have relevant knowledge. We use the Classical Model of structured expert judgment to elicit projections with uncertainty bounds of resistance rates through 2026 for nine pathogen-antibiotic pairs in four European countries and empirically validate the assessments against data on a set of calibration questions. The performance-weighted combination of experts in France, Spain, and the United Kingdom projected that resistance for five pairs on the World Health Organization’s priority pathogens list (E. coli and K. pneumoniae resistant to third-generation cephalosporins and carbapenems and MRSA) would remain below 50% in 2026. In Italy, although upper bounds of 90% credible ranges exceed 50% resistance for some pairs, the medians suggest Italy will sustain or improve its current rates. We compare these expert projections to statistical forecasts based on historical data from the European Antimicrobial Resistance Surveillance Network (EARS-Net). Results from the statistical models differ from each other and from the judgmental forecasts in many cases. The judgmental forecasts include information from the experts about the impact of current and future shifts in infection control, antibiotic usage, and other factors that cannot be easily captured in statistical forecasts, demonstrating the potential of structured expert judgment as a tool for better understanding the uncertainty about future antibiotic resistance.
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Affiliation(s)
- Abigail R. Colson
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
- * E-mail:
| | - Itamar Megiddo
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
| | - Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Andhra Pradesh, India
| | - Sumanth Gandra
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
| | - Tim Bedford
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
| | - Alec Morton
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
| | - Roger M. Cooke
- Resources for the Future, Washington, DC, United States of America
- TU Delft, Delft, The Netherlands
| | - Ramanan Laxminarayan
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
- Princeton Environmental Institute, Princeton University, Princeton, New Jersey, United States of America
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Ambroggio L, Schondelmeyer A, Hoefgen E, Brady P, Shaughnessy E. Quality Improvement Feature Series Article 4: Advanced Designs for Quality Improvement Studies. J Pediatric Infect Dis Soc 2018; 7:335-337. [PMID: 29045666 DOI: 10.1093/jpids/pix082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/28/2017] [Indexed: 11/12/2022]
Abstract
Each quality improvement (QI) project has an implicit study design, although these designs are not discussed as commonly as they are in clinical research. Most QI projects fall under the quasi-experimental study category, in which observations are made before and after the implementation of an intervention(s). The simplest and most commonly used for QI studies is the pre-post design, in which observations are made before and after each intervention that was implemented over a specified period. More sophisticated designs for QI studies enable a study team to draw stronger inferences about the system that is being changed and the individual effects of the interventions that are implemented. In the final commentary in this QI series, we discuss these study designs and focus on the strengths and weaknesses of more sophisticated designs, including cluster randomized, stepped-wedge, and factorial designs.
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Affiliation(s)
- Lilliam Ambroggio
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Amanda Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Erik Hoefgen
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Patrick Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Erin Shaughnessy
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
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4
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Systematic review of the use of time series data in the study of antimicrobial consumption and Pseudomonas aeruginosa resistance. J Glob Antimicrob Resist 2018; 15:69-73. [DOI: 10.1016/j.jgar.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/30/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022] Open
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Catry B. Antimicrobial policies in animals and human health. Arch Public Health 2017; 75:62. [PMID: 29075486 PMCID: PMC5648479 DOI: 10.1186/s13690-017-0231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 08/28/2017] [Indexed: 11/10/2022] Open
Abstract
This invited commentary aims to highlight 3 recommendations to rationalize antimicrobial consumption in livestock, in order to minimize the spread of resistant bacteria and simultaneously safeguarding animal and public health.
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Affiliation(s)
- Boudewijn Catry
- Healthcare-Associated Infections & Antimicrobial Resistance, Operational Directorate of Public Health and Surveillance, Scientific Institute of Public Health (WIV-ISP), J. Wytsmanstraat 14, 1050 Brussels, Belgium
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Burke LK, Brown CP, Johnson TM. Historical Data Analysis of Hospital Discharges Related to the Amerithrax Attack in Florida. PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2016; 13:1c. [PMID: 27843420 PMCID: PMC5075231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Interrupted time-series analysis (ITSA) can be used to identify, quantify, and evaluate the magnitude and direction of an event on the basis of time-series data. This study evaluates the impact of the bioterrorist anthrax attacks ("Amerithrax") on hospital inpatient discharges in the metropolitan statistical area of Palm Beach, Broward, and Miami-Dade counties in the fourth quarter of 2001. Three statistical methods-standardized incidence ratio (SIR), segmented regression, and an autoregressive integrated moving average (ARIMA)-were used to determine whether Amerithrax influenced inpatient utilization. The SIR found a non-statistically significant 2 percent decrease in hospital discharges. Although the segmented regression test found a slight increase in the discharge rate during the fourth quarter, it was also not statistically significant; therefore, it could not be attributed to Amerithrax. Segmented regression diagnostics preparing for ARIMA indicated that the quarterly data time frame was not serially correlated and violated one of the assumptions for the use of the ARIMA method and therefore could not properly evaluate the impact on the time-series data. Lack of data granularity of the time frames hindered the successful evaluation of the impact by the three analytic methods. This study demonstrates that the granularity of the data points is as important as the number of data points in a time series. ITSA is important for the ability to evaluate the impact that any hazard may have on inpatient utilization. Knowledge of hospital utilization patterns during disasters offer healthcare and civic professionals valuable information to plan, respond, mitigate, and evaluate any outcomes stemming from biothreats.
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Affiliation(s)
- Lauralyn K Burke
- Division of Health Informatics and Information Management at Florida A&M University in Tallahassee, FL
| | - C Perry Brown
- Public health in the Institute of Public Health at the College of Pharmacy and Pharmaceutical Sciences at Florida A&M University in Tallahassee, FL
| | - Tammie M Johnson
- Department of Public Health at the University of North Florida in Jacksonville, FL
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Timbrook TT, Hurst JM, Bosso JA. Impact of an Antimicrobial Stewardship Program on Antimicrobial Utilization, Bacterial Susceptibilities, and Financial Expenditures at an Academic Medical Center. Hosp Pharm 2016; 51:703-711. [PMID: 27803499 DOI: 10.1310/hpj5109-703] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Antimicrobial stewardship programs (ASPs) have the potential to improve patient outcomes, decrease microbial resistance, increase patient safety, and decrease costs. However, to justify the costs involved with providing an ASP, it is necessary to assess its impact in achieving these outcomes on an ongoing basis. Objective: The purpose of this study was to characterize the overall impact of the ASP at an Academic medical center. Methods: Quasi-experimental, before and after stewardship program implementation, retrospective analyses of quarterly antimicrobial utilization, bacterial susceptibilities, and antibiotic acquisition costs were utilized. Results: Mean stewardship-focused antibiotic utilization was 510.3 defined daily doses (DDD) per 1,000 patient days for the pre-ASP period and 426.4 DDD per 1,000 patient days for the ASP period (16.4% decrease; p < .001). Significant changes in Pseudomonas aeruginosa susceptibility to tobramycin (8% increase; p = .006) and piperacillin-tazobactam (8% decrease; p = .024) were noted. Changes in susceptibility of Staphylococcus aureus to methicillin (7% increase, p = .012) were also observed. ASP-focused antibiotic expenditures decreased from $4,028,068 in fiscal year (FY) 2010 to $2,135,173 in FY2013 (p = .01). Conclusions: ASP initiatives were associated with an observed reduction in stewardship-focused antibiotic utilization. Significant changes in susceptibilities of some bacteria were noted but did not seem to consistently reflect antibiotic utilization changes. Significant decreases in antimicrobial expenditures were observed. Observed outcomes are temporally related to shifts in antimicrobial selection through the initiation of stewardship program-driven antibiotic policy changes. These outcomes have been used to justify and expand our stewardship program moving forward.
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Fuzi M. Dissimilar Fitness Associated with Resistance to Fluoroquinolones Influences Clonal Dynamics of Various Multiresistant Bacteria. Front Microbiol 2016; 7:1017. [PMID: 27458434 PMCID: PMC4935693 DOI: 10.3389/fmicb.2016.01017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/15/2016] [Indexed: 01/24/2023] Open
Abstract
Fitness cost associated with resistance to fluoroquinolones was recently shown to vary across clones of methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing Klebsiella pneumoniae. The resulting dissimilar fitness should have influenced the clonal dynamics and thereby the rates of resistance for these pathogens. Moreover, a similar mechanism was recently proposed for the emergence of the H30 and H30R lineages of ESBL-producing E. coli and the major international clone (ribotype 027) of Clostridium difficile. Furthermore, several additional international clones of various multiresistant bacteria are suspect to have been selected by an analogous process. An ability to develop favorable mutations in the gyrase and topoisomerase IV genes seems to be a prerequisite for pathogens to retain fitness while showing high-level resistance to fluoroquinolones. Since, the consumption of other "non-fluoroquinolone" groups of antibiotics have also contributed to the rise in resistance rates a more judicious use of antibiotics in general and of fluoroquinolones in particular could ameliorate the international resistance situation.
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Affiliation(s)
- Miklos Fuzi
- Institute of Medical Microbiology, Semmelweis UniversityBudapest, Hungary
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9
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Borg MA, Suda D, Scicluna E. Time-Series Analysis of the Impact of Bed Occupancy Rates on the Incidence of Methicillin-Resistant Staphylococcus aureus Infection in Overcrowded General Wards. Infect Control Hosp Epidemiol 2015; 29:496-502. [DOI: 10.1086/588157] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.We investigated the impact of bed occupancy, particularly overcrowding, on the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection in general ward settings.Methods.We performed a time-series and mixed-model analysis of variance of monthly incidence of MRSA infection and corresponding bed occupancy rates, over 65 months, in the medicine and surgical wards within St. Luke's Hospital, a 900-bed tertiary care facility in Malta.Results.In the medicine wards, significant periodic fluctuations in bed demand were evident during the study period, with peaks of occupancy greater than 120% during the winter months. Cross-correlation analysis between the rate of bed occupancy and the rate of MRSA infection displayed an oscillatory configuration, with a periodicity of 12, similar to the periodicity evident in the autocorrelation bed-occupancy pattern. Further statistical analysis by means of analysis of variance confirmed that the months with excessive overcrowding tended to coincide with a significant increase in the rate of MRSA infection, occurring after a lag of approximately 2 months. Identical analysis of equivalent data from the surgical wards also revealed significant fluctuation in the rate of bed occupancy; however, occupancy never exceeded 100%. No cross-correlational relationship with MRSA infection incidence was present.Conclusion.The study data suggest that, in our setting, simple fluctuations in the rate of bed occupancy did not have a direct impact on the incidence of MRSA infection as long as the rate of bed occupancy was within designated levels. Rather, it was episodes of significant overcrowding, with occupancy levels in excess of designated numbers, that triggered increases in infection incidence rates.
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10
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Füzi M. Has the use of fluoroquinolones facilitated the widespread dissemination of methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing Klebsiella pneumoniae in the healthcare setting? Acta Microbiol Immunol Hung 2014; 61:399-405. [PMID: 25361527 DOI: 10.1556/amicr.61.2014.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Our group recently demonstrated that diverse fitness cost associated with resistance to fluoroquinolones allowed the extensive dissemination of the major international clones of both methicillin-resistant Staphylococcus aureus (MRSA) and multiresistant Klebsiella pneumoniae in the healthcare setting. The mechanism described by us was subsequently confirmed by British authors investigating the dynamics of MRSA clones in England. Our results imply that the use of fluoroquinolones should impact the incidence for both MRSA and multiresistant K. pneumoniae. A review of the related clinical studies mostly support this notion and shows that changes in the consumption of fluoroquinolone type antibiotics and the rates for both MRSA and multiresistant ESBL-producing K. pneumoniae remain usually in accordance. Though the association seems strong and the mechanism behind it unequivocal the use of fluoroquinolones should not be abandoned; a more judicious application can be recommended.
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Affiliation(s)
- Miklós Füzi
- 1 Semmelweis University Institute of Medical Microbiology Budapest Hungary
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11
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Cheng VCC, Tai JWM, Chau PH, Chen JHK, Yan MK, So SYC, To KKW, Chan JFW, Wong SCY, Ho PL, Yuen KY. Minimal intervention for controlling nosocomial transmission of methicillin-resistant staphylococcus aureus in resource limited setting with high endemicity. PLoS One 2014; 9:e100493. [PMID: 24945412 PMCID: PMC4063951 DOI: 10.1371/journal.pone.0100493] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/23/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To control nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) in resource-limited healthcare setting with high endemicity. METHODS Three phases of infection control interventions were implemented in a University-affiliated hospital between 1-January-2004 and 31-December-2012. The first phase of baseline period, defined as the first 48-months of the study period, when all MRSA patients were managed with standard precautions, followed by a second phase of 24-months, when a hospital-wide hand hygiene campaign was launched. In the third phase of 36-months, contact precautions in open cubicle, use of dedicated medical items, and 2% chlorhexidine gluconate daily bathing for MRSA-positive patients were implemented while hand hygiene campaign was continued. The changes in the incidence rates of hospital-acquired MRSA-per-1000-patient admissions, per-1000-patient-days, and per-1000-MRSA-positive-days were analyzed using segmented Poisson regression (an interrupted time series model). Usage density of broad-spectrum antibiotics was monitored. RESULTS During the study period, 4256 MRSA-positive patients were newly diagnosed, of which 1589 (37.3%) were hospital-acquired. The reduction of hospital-acquired MRSA per 1000-patient admissions, per 1000-patient-days, and per 1000-MRSA-positive-days from phase 1 to 2 was 36.3% (p<0.001), 30.4% (p<0.001), and 19.6% (p = 0.040), while the reduction of hospital-acquired MRSA per 1000-patient admissions, per 1000-patient-days, and per 1000-MRSA-positive-days from phase 2 to 3 was 27.4% (p<0.001), 24.1% (p<0.001), and 21.9% (p = 0.041) respectively. This reduction is sustained despite that the usage density of broad-spectrum antibiotics has increased from 132.02 (phase 1) to 168.99 per 1000 patient-days (phase 3). CONCLUSIONS Nosocomial transmission of MRSA can be reduced with hand hygiene campaign, contact precautions in open cubicle, and 2% chlorhexidine gluconate daily bathing for MRSA-positive despite an increasing consumption of broad-spectrum antibiotics.
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Affiliation(s)
- Vincent Chi-Chung Cheng
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Infection Control Team, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Josepha Wai-Ming Tai
- Infection Control Team, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Pui-Hing Chau
- School of Nursing, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jonathan Hon-Kwan Chen
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Mei-Kum Yan
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Simon Yung-Chun So
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Kelvin Kai-Wang To
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jasper Fuk-Woo Chan
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Sally Cheuk-Ying Wong
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Pak-Leung Ho
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kwok-Yung Yuen
- Department of Microbiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong Special Administrative Region, China
- * E-mail:
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Schulz LT, Fox BC, Polk RE. Can the antibiogram be used to assess microbiologic outcomes after antimicrobial stewardship interventions? A critical review of the literature. Pharmacotherapy 2013; 32:668-76. [PMID: 23307516 DOI: 10.1002/j.1875-9114.2012.01163.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hospitals are implementing antimicrobial stewardship programs (ASPs) in response to national guidelines to improve the use and to extend the utility of antiinfective drugs. An often implied purpose of ASPs is to curb or reverse the emergence of resistant bacteria. Because antibiotic use causes antibiotic resistance, there is a natural tendency to link local measures of antibiotic use to local measures of bacterial resistance, and the hospital antibiogram is a readily available measure of resistance. We performed a literature review to identify published reports that used hospitalwide and unit-specific antibiograms to assess the relationship of ASP interventions to changes in resistance. Eight studies were identified and reviewed. The relationship between hospital antibiotic use and resistance is complex, and the existing literature has several limitations. Furthermore, the antibiogram itself is neither designed nor well suited to reflect changes in hospital antimicrobial drug use. The literature on the effectiveness of ASPs in reducing resistance continues to emerge, but at this time the antibiogram bears an inconsistent relationship with changes in hospital antibiotic use and cannot be recommended to reliably evaluate an ASP intervention. Interrupted time series analysis is a superior strategy to assess the effect of an ASP intervention on bacterial resistance, but it is not widely used because of its complexity and greater data requirements. Nevertheless, before ASP efforts can be convincingly demonstrated to have a favorable impact on resistance, a more sophisticated approach that links drug use to resistance should become a priority, at least for hospitals that have sufficient resources.
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Affiliation(s)
- Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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The Economic Impact of Starting, Stopping, and Restarting an Antibiotic Stewardship Program: A 14-Year Experience. Antibiotics (Basel) 2013; 2:256-64. [PMID: 27029302 PMCID: PMC4790338 DOI: 10.3390/antibiotics2020256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 04/11/2013] [Accepted: 04/15/2013] [Indexed: 11/16/2022] Open
Abstract
Regions Hospital started a multidisciplinary antibiotic stewardship program (ASP) in 1998. The program effectively shut down from 2002–2004 as key personnel departed and was then restarted but without the dedicated pharmacist and infectious diseases physician. Purchasing data (in dollars or dollars/patient/day) unadjusted for inflation served as a surrogate marker of antibiotic consumption. These data were reviewed monthly, quarterly, and yearly along with antibiotic susceptibility patterns on a semi-annual basis. Segmented regression analysis was use to compare restricted antibiotic purchases for performance periods of 1998–2001 (construction), 2002–2004 (de-construction), and 2005–2011 (reconstruction). After 4 years (1998–2001) of operation, a number of key participants of the ASP departed. For the following three years (2002–2004) the intensity and focus of the program floundered. This trend was averted when the program was revitalized in early 2005. The construction, deconstruction, and reconstruction of our ASP provided a unique opportunity to statistically examine the financial impact of our ASP or lack thereof in the same institution. We demonstrate a significant economic impact during ASP deconstruction and reconstruction.
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Madaras-Kelly KJ, Remington RE, Fan VS, Sloan KL. Predicting antibiotic resistance to community-acquired pneumonia antibiotics in culture-positive patients with healthcare-associated pneumonia. J Hosp Med 2012; 7:195-202. [PMID: 22038859 PMCID: PMC4778425 DOI: 10.1002/jhm.942] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 04/27/2011] [Accepted: 05/02/2011] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To develop and validate a model to predict resistance to community-acquired pneumonia antibiotics (CAP-resistance) among patients with healthcare-associated pneumonia (HCAP), and to compare the model's predictive performance to a model including only guideline-defined criteria for HCAP. DESIGN Retrospective cohort study. SETTING Six Veterans Affairs Medical Centers in the northwestern United States. PATIENTS Culture-positive inpatients with HCAP. MEASUREMENTS Patients were identified based upon guideline-defined criteria for HCAP. Relevant cultures obtained within 48 hours of admission were assessed to determine bacteriology and antibiotic susceptibility. Medical records for the year preceding admission were assessed to develop predictive models of CAP-resistance with logistic regression. The predictive performance of cohort-developed and guideline-defined models was compared. RESULTS CAP-resistant organisms were identified in 118 of 375 culture-positive patients. Of guideline-defined criteria, CAP-resistance was associated (odds ratio (OR) [95% confidence interval (CI)]) with: admission from nursing home (2.6 [1.6-4.4]); recent antibiotic exposure (1.7 [1.0-2.8]); and prior hospitalization (1.6 [1.0-2.6]). In the cohort-developed model, CAP-resistance was associated with: admission from nursing home or recent nursing home discharge (2.3 [1.4-3.8]); positive methicillin-resistant Staphylococcus aureus (MRSA) history within 90 days of admission (6.4 [2.6-17.8]) or 91-365 days (2.3 [0.9-5.9]); cephalosporin exposure (1.8 [1.1-2.9]); recent infusion therapy (1.9 [1.0-3.5]); diabetes (1.7 [1.0-2.8]); and intensive care unit (ICU) admission (1.6 [1.0-2.6]). Area under the receiver operating characteristic curve (aROC [95% CI]) for the cohort-developed model (0.71 [0.65-0.77]) was significantly higher than for the guideline-defined model (0.63 [0.57-0.69]) (P = 0.01). CONCLUSIONS Select guideline-defined criteria predicted CAP-resistance. A cohort-developed model based primarily on prior MRSA history, nursing home residence, and specific antibiotic exposures provided improved prediction of CAP-resistant organisms in HCAP.
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Affiliation(s)
- Karl J Madaras-Kelly
- Clinical Pharmacy Service (119A), Veterans Affairs Medical Center, Boise, ID 83702, USA.
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15
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Modelling interrupted time series to evaluate prevention and control of infection in healthcare. Epidemiol Infect 2012; 140:2131-41. [PMID: 22335933 DOI: 10.1017/s0950268812000179] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The most common methods for evaluating interventions to reduce the rate of new Staphylococcus aureus (MRSA) infections in hospitals use segmented regression or interrupted time-series analysis. We describe approaches to evaluating interventions introduced in different healthcare units at different times. We compare fitting a segmented Poisson regression in each hospital unit with pooling the individual estimates by inverse variance. An extension of this approach to accommodate potential heterogeneity allows estimates to be calculated from a single statistical model: a 'stacked' model. It can be used to ascertain whether transmission rates before the intervention have the same slope in all units, whether the immediate impact of the intervention is the same in all units, and whether transmission rates have the same slope after the intervention. The methods are illustrated by analyses of data from a study at a Veterans Affairs hospital. Both approaches yielded consistent results. Where feasible, a model adjusting for the unit effect should be fitted, or if there is heterogeneity, an analysis incorporating a random effect for units may be appropriate.
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16
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Abstract
Antimicrobial resistance is increasing; however, antimicrobial drug development is slowing. Now more than ever before, antimicrobial stewardship is of the utmost importance as a way to optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. This review describes the why, what, who, how, when, and where of antimicrobial stewardship. Techniques of stewardship are summarized, and a plan for implementation of a stewardship program is outlined.
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Affiliation(s)
- Shira Doron
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA 02111, USA
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Church EC, Mauldin PD, Bosso JA. Antibiotic resistance in Pseudomonas aeruginosa related to quinolone formulary changes: an interrupted time series analysis. Infect Control Hosp Epidemiol 2011; 32:400-2. [PMID: 21460495 DOI: 10.1086/659157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Pseudomonas aeruginosa is a nosocomial pathogen capable of exhibiting a variety of resistance mechanisms against multiple classes of antibiotics. Fluoroquinolones, commonly used to treat a variety of infections in both ambulatory and hospitalized patients, have been increasingly linked to the development of resistance, both to fluoroquinolones and to other classes of antibiotics including β-lactams, cephalosporins, and carbapenems. In turn, as many as 95% of multidrug-resistant pseudomonal isolates may be resistant to fluoroquinolones. Although research has examined the effect of fluoroquinolone use on P. aeruginosa resistance, to our knowledge, no work has been published describing possible differences among individual fluoroquinolones related to resistance to other antibiotic classes. The purpose of this analysis was to assess the possible effects of varying usage of levofloxacin, gatifloxacin, and moxifloxacin on P. aeruginosa susceptibility to piperacillin-tazobactam, cefepime, and tobramycin. Data from January 2000 through December 2008 were obtained from clinical microbiology and pharmacy databases of the Medical University of South Carolina Medical Center, which is a 689-bed academic medical center and level 1 trauma center with adult and pediatric beds. This study was approved by the institution's institutional review board.
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Affiliation(s)
- E Chandler Church
- Department of Pharmacy and Clinical Sciences, South Carolina College of Pharmacy, SC, USA.
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18
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Parienti JJ, Cattoir V, Thibon P, Lebouvier G, Verdon R, Daubin C, du Cheyron D, Leclercq R, Charbonneau P. Hospital-wide modification of fluoroquinolone policy and meticillin-resistant Staphylococcus aureus rates: a 10-year interrupted time-series analysis. J Hosp Infect 2011; 78:118-22. [PMID: 21497946 DOI: 10.1016/j.jhin.2011.03.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
Abstract
In our tertiary university hospital, fluoroquinolones were prohibited during 2001 leading to a 90% reduction in their use. Our objective was to examine the trends in meticillin-resistant Staphylococcus aureus (MRSA) following the reintroduction of fluoroquinolones. We conducted a 10-year time-series analysis of monthly MRSA according to: (i) period of fluoroquinolone restriction (January 2001 to January 2002); (ii) period of fluoroquinolone increase up to pre-restriction levels (January 2002 to December 2004); and (iii) an observational period including the implementation of a hand hygiene campaign with alcohol-based hand rub (January 2005 to June 2009). We used segmented linear autoregression analysis to assess trends between adjacent periods. Fluoroquinolone use increased from 5.2 defined daily doses (DDD) per 1000 patient-days in 2001 to 56.6 DDD per 1000 patient-days in 2005 reaching pre-restriction fluoroquinolone levels (P<0.001) and remained stable during 2005-2010 (P=0.65). The monthly proportion of MRSA decreased during the period of FQ restriction (-0.49 per month, P<0.05). The reintroduction of fluoroquinolones was associated with a significant increase in MRSA (+0.68 per month, P<0.02) compared to the previous period. During period 3, we observed a significant change in MRSA (-5.9, P<0.002) compared to the previous period (-0.32 per month, P<0.001). During the latter period, hand hygiene was promoted and alcohol-based hand-rub consumption increased from 3411 L in 2005 to 14,599 L in 2009. This study reinforces the rationale for a hospital-wide fluoroquinolone formulary policy to control MRSA and suggests that it has an additive effect with a hand hygiene promotion.
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Affiliation(s)
- J-J Parienti
- Department of Biostatistics and Clinical Research, CHU de Caen, Caen, France.
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19
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Changes in antibiotic usage and susceptibility in nosocomial Enterobacteriaceae and Pseudomonas isolates following the introduction of ertapenem to hospital formulary. Epidemiol Infect 2011; 140:115-25. [DOI: 10.1017/s0950268811000082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
SUMMARYThere is concern that widespread usage of ertapenem may promote cross-resistance to other carbapenems. To analyse the impact that adding ertapenem to our hospital formulary had on usage of other broad-spectrum agents and on susceptibilities of nosocomial Enterobacteriaceae and Pseudomonas isolates, we performed interrupted time-series analyses to determine the change in linear trend in antibiotic usage and change in mean proportion and linear trend of susceptibility pre- (March 2004–June 2005) and post- (July 2005–December 2008) ertapenem introduction. Usage of piperacillin-tazobactam (P=0·0013) and ampicillin-sulbactam (P=0·035) declined post-ertapenem introduction. For Enterobacteriaceae, the mean proportion susceptible to ciprofloxacin (P=0·016) and piperacillin-tazobactam (P=0·038) increased, while the linear trend in susceptibility significantly increased for cefepime (P=0·012) but declined for ceftriaxone (P=0·0032). For Pseudomonas, the mean proportion susceptible to cefepime (P=0·011) and piperacillin-tazobactam (P=0·028) increased, as did the linear trend in susceptibility to ciprofloxacin (P=0·028). Notably, no significant changes in carbapenem susceptibility were observed.
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Cox LAT, Popken DA. Assessing potential human health hazards and benefits from subtherapeutic antibiotics in the United States: tetracyclines as a case study. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2010; 30:432-457. [PMID: 20136749 DOI: 10.1111/j.1539-6924.2009.01340.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Many scientists, activists, regulators, and politicians have expressed urgent concern that using antibiotics in food animals selects for resistant strains of bacteria that harm human health and bring nearer a "postantibiotic era" of multidrug resistant "super-bugs." Proposed political solutions, such as the Preservation of Antibiotics for Medical Treatment Act (PAMTA), would ban entire classes of subtherapeutic antibiotics (STAs) now used for disease prevention and growth promotion in food animals. The proposed bans are not driven by formal quantitative risk assessment (QRA), but by a perceived need for immediate action to prevent potential catastrophe. Similar fears led to STA phase-outs in Europe a decade ago. However, QRA and empirical data indicate that continued use of STAs in the United States has not harmed human health, and bans in Europe have not helped human health. The fears motivating PAMTA contrast with QRA estimates of vanishingly small risks. As a case study, examining specific tetracycline uses and resistance patterns suggests that there is no significant human health hazard from continued use of tetracycline in food animals. Simple hypothetical calculations suggest an unobservably small risk (between 0 and 1.75E-11 excess lifetime risk of a tetracycline-resistant infection), based on the long history of tetracycline use in the United States without resistance-related treatment failures. QRAs for other STA uses in food animals also find that human health risks are vanishingly small. Whether such QRA calculations will guide risk management policy for animal antibiotics in the United States remains to be seen.
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Meyer E, Schwab F, Pollitt A, Bettolo W, Schroeren-Boersch B, Trautmann M. Impact of a change in antibiotic prophylaxis on total antibiotic use in a surgical intensive care unit. Infection 2009; 38:19-24. [PMID: 19904488 DOI: 10.1007/s15010-009-9115-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 08/24/2009] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of reducing the length of antibiotic prophylaxis for cerebro spinal shunts on total antibiotic use and key resistant pathogens. METHODS In January 2004, the use of antibiotic prophylaxis was reduced to a single shot dose with cefuroxime in an intensive care unit (ICU). Prior to this intervention, prophylaxis with second-generation cephalosporins was administered during the entire period of external cerebro spinal fluid (CSF) drainage. The effect on the antibiotic use density (AD: DDD [defined daily doses] per 1,000 patient-days[pd]) was calculated prior to (January 2002-December 2003) and following implementation of the intervention(January 2004-December 2006) by segmented regression analysis of an interrupted time series. Resistance proportions(RP) and resistance densities (RD), defined as resistant pathogen/1,000 pd of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis or E. faecium, third-generation-resistant (3GC) Escherichia coli and Klebsiella pneumoniae, and imipenem-resistant Pseudomonus aeruginosa, were compared by the Fisher's exact test before and after the intervention. RESULTS Total antibiotic use by 147 DDD/1,000 pd decreased after the intervention when pre-operative prophylaxis was changed into single shot prophylaxis, from an estimated mean of 1,036 DDD/1,000 pd before the intervention to 887DDD/1,000 pd post-intervention. This decrease was primarily due to a significant reduction in the amount of cefuroxime used for prophylaxis. The reduction in total antibiotic consumption was sustainable, and it did not increase again during the next 36 months. The RR and RD of third-generation cephalosporin-resistant E. coli increased after January 2004, whereas the percentage of MRSA significantly decreased. CONCLUSION Change to single shot prophylaxis along with an ongoing antibiotic stewardship program resulted in a cut-back in total antibiotic use amounting to as much as 15%. It would therefore appear that targeting interventions aimed at reducing antibiotic prophylaxis in surgical ICUs may be very worthwhile.
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Affiliation(s)
- E Meyer
- Institute of Hygiene and Environmental Medicine, Charité UniversityMedicine, Berlin, Germany.
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22
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Maortua H, Canut A, Ibáñez B, Martínez D, de Domingo MJ, Labora A. Relación entre la resistencia bacteriana intrahospitalaria y el consumo de antimicrobianos durante un período de 13 años. Enferm Infecc Microbiol Clin 2009; 27:441-8. [DOI: 10.1016/j.eimc.2008.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 08/06/2008] [Accepted: 08/31/2008] [Indexed: 12/01/2022]
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23
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Harbarth S, Samore MH. Interventions to control MRSA: high time for time-series analysis? J Antimicrob Chemother 2008; 62:431-3. [DOI: 10.1093/jac/dkn240] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Vernaz N, Sax H, Pittet D, Bonnabry P, Schrenzel J, Harbarth S. Temporal effects of antibiotic use and hand rub consumption on the incidence of MRSA and Clostridium difficile. J Antimicrob Chemother 2008; 62:601-7. [PMID: 18468995 DOI: 10.1093/jac/dkn199] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine the temporal relation between the use of antibiotics and alcohol-based hand rubs (ABHRs) and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. METHODS An interventional time-series analysis was performed to evaluate the impact of two promotion campaigns on the consumption of ABHRs and to assess their effect on the incidence of non-duplicate clinical isolates of MRSA and C. difficile from February 2000 through September 2006. This analysis was combined with a transfer function model of aggregated data on antibiotic use. RESULTS Consumption of ABHRs correlated with MRSA, but not with C. difficile. The final model demonstrated the immediate effect of the second hand hygiene promotion campaign and an additional temporal effect of fluoroquinolone (time lag, 1 month; i.e. antibiotic effect delayed for 1 month), macrolide (lag 1 and 4 months), broad-spectrum cephalosporins (lag 3, 4 and 5 months) and piperacillin/tazobactam (lag 3 months) use. The final model explained 57% of the MRSA variance over time. In contrast, the model for C. difficile showed only an effect for broad-spectrum cephalosporins (lag 1 month). CONCLUSIONS We observed an aggregate-level relation between the monthly MRSA incidence and the use of different antibiotic classes and increased consumption of ABHR after a successful hand hygiene campaign, while no association with ABHR use was detected for C. difficile.
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Affiliation(s)
- Nathalie Vernaz
- Pharmacy Department, University of Geneva Hospitals and Medical School, Geneva, Switzerland
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25
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Mauldin PD, Salgado CD, Durkalski VL, Bosso JA. Nosocomial infections due to methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus: relationships with antibiotic use and cost drivers. Ann Pharmacother 2008; 42:317-26. [PMID: 18285560 DOI: 10.1345/aph.1k501] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Increased incidence of nosocomial infections due to methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) has been associated with the use of certain antibiotics and has resulted in increased morbidity, mortality, and costs of care. OBJECTIVE To describe relationships between vancomycin and linezolid use and incidence of these nosocomial infections over time and to determine factors associated with the increased costs of care (cost drivers) associated with affected patients. METHODS The association between institution-wide antibiotic use and the rate of nosocomial MRSA and VRE infections was assessed using segmented regression analysis for interrupted time series. The effect that patient characteristics and procedures, as well as certain antibiotic use, had on costs and length of stay of patients with MRSA or VRE nosocomial infection was also assessed and cost drivers for the 2 types of infections were compared. RESULTS Our analysis included 206 patients who developed MRSA (n = 187) or VRE (n = 19) nosocomial infection. Although small numbers of VRE nosocomial infection may limit generalizations from our results, we found no significant relationship between vancomycin or linezolid use and the rate of either infection. While mean hospital costs were similar, cost drivers varied somewhat between infection types. CONCLUSIONS The incidence of MRSA or VRE infections does not appear to be related to the use of vancomycin or linezolid. Costs of care are quite high in some affected patients and, while mean total hospital costs are similar, cost drivers appear to differ between the 2 infection types.
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Affiliation(s)
- Patrick D Mauldin
- Department of Clinical Pharmacy and Outcome Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, SC 29425, USA
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Abstract
In response to the global antibiotic resistance crisis, antimicrobial stewardship programs have emerged throughout the United States. Effective programs integrate several strategic methods, including evaluation and feedback regarding the necessity and appropriateness of antimicrobial therapy, staff education, and formulary restrictions. Multidisciplinary teams as well as institutional support are needed to form effective subcommittees to monitor national and local surveillance reports and resistance patterns, and to update antibiograms. Computerized decision support programs have been effective and successful methods of antimicrobial stewardship and can be a powerful tool in stewardship programs. Successful programs have reduced not only institutional resistance rates, but also morbidity, mortality, and cost.
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Affiliation(s)
- Michael J Rybak
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan 48201, USA
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Valiquette L, Cossette B, Garant MP, Diab H, Pépin J. Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic of Clostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain. Clin Infect Dis 2007; 45 Suppl 2:S112-21. [PMID: 17683015 DOI: 10.1086/519258] [Citation(s) in RCA: 259] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
A series of measures were implemented, in a secondary/tertiary-care hospital in Quebec, to control an epidemic of nosocomial Clostridium difficile-associated disease (n-CDAD) caused by a virulent strain; these measures included the development of a nonrestrictive antimicrobial stewardship program. Interrupted time-series analysis was used to evaluate the impact of these measures on n-CDAD incidence. From 2003-2004 to 2005-2006, total and targeted antibiotic consumption, respectively, decreased by 23% and 54%, and the incidence of n-CDAD decreased by 60%. No change in n-CDAD incidence was noted after strengthening of infection control procedures (P=.63), but implementation of the antimicrobial stewardship program was followed by a marked reduction in incidence (P=.007). This suggests that nonrestrictive measures to optimize antibiotic usage can yield exceptional results when physicians are motivated and that such measures should be a mandatory component of n-CDAD control. The inefficacy of infection control measures targeting transmission through hospital personnel might be a result of their implementation late in the epidemic, when the environment was heavily contaminated with spores.
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Affiliation(s)
- Louis Valiquette
- Department of Microbiology and Infectious Diseases, University of Sherbrooke, Sherbrooke, Quebec, Canada.
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Marshall C, Black J. Education-based intervention to prevent catheter-associated bloodstream infection. Infect Control Hosp Epidemiol 2007; 28:370; author reply 370-1. [PMID: 17326036 DOI: 10.1086/512643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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