Sulis G, Sayood S, Katukoori S, Bollam N, George I, Yaeger LH, Chavez MA, Tetteh E, Yarrabelli S, Pulcini C, Harbarth S, Mertz D, Sharland M, Moja L, Huttner B, Gandra S. Exposure to World Health Organization's AWaRe antibiotics and isolation of multidrug resistant bacteria: a systematic review and meta-analysis.
Clin Microbiol Infect 2022;
28:1193-1202. [PMID:
35339675 DOI:
10.1016/j.cmi.2022.03.014]
[Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND
Antibiotic use drives antibiotic resistance.
OBJECTIVES
To systematically review the literature and estimate associations between prior exposure to antibiotics across World Health Organization's (WHO) AWaRe categories (Access, Watch, Reserve) and isolation of critical and high-priority multidrug resistant organisms (MDROs) on the WHO priority pathogen list.
DATA SOURCES
Embase, Ovid Medline, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov (from inception to 20/08/2020).
STUDY ELIGIBILITY CRITERIA
Case-control, cohort, or experimental studies that assessed the risk of infection/colonization with MDROs.
PARTICIPANTS
Inpatients or outpatients of any age and sex.
INTERVENTIONS
Prior exposure to antibiotics that could be categorized into the AWaRe framework.
DATA ANALYSIS
Tailored design-specific checklists applied to each included study. For each antibiotic/class, crude odds ratios (ORs) were pooled through random-effects meta-analyses, both overall and by MDRO. Heterogeneity was examined.
RESULTS
We identified 349 eligible studies. All were observational, prone to bias due to design and lack of adjustment for confounding, and not primarily designed to compare associations across AWaRe categories. We found statistically significant associations between prior exposure to almost all antibiotics/classes across AWaRe categories and colonization/infection with any MDRO. We observed higher ORs for Watch and Reserve antibiotics than with Access antibiotics. First generation cephalosporins (Access) had the least association with any MDRO colonization/infection (58 studies; OR = 1.2 [95% CI: 1.0-1.4]), whereas strongest associations were estimated for linezolid (Reserve) (22 studies; OR = 2.6 [95% CI: 2.1-3.1]), followed by carbapenems (Watch) (237 studies; OR = 2.3 [95% CI: 2.1-2.5]). There was high heterogeneity for all antibiotic/MDRO associations.
CONCLUSIONS
Optimising use of Access antibiotics is likely to reduce the selection of MDROs and global antibiotic resistance. Despite data limitations, our study offers a strong rationale for further adoption of AWaRe as an important tool to improve antibiotic use globally.
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