Cefepime restriction improves gram-negative overall resistance patterns in neonatal intensive care unit

Abstract

Antibiotic restriction can be useful in maintaining bacterial susceptibility. The objective of this study was verify if restriction of cefepime, the most frequently used cephalosporin in our neonatal intensive care unit (NICU), would ameliorate broad-spectrum susceptibility of Gram-negative isolates. Nine hundred and ninety-five premature and term newborns were divided into 3 cohorts, according to the prevalence of cefepime use in the unit: Group 1 (n=396) comprised patients admitted from January 2002 to December 2003, period in which cefepime was the most used broad-spectrum antibiotic. Patients in Group 2 (n=349) were admitted when piperacillin/tazobactam replaced cefepime (January to December 2004) and in Group 3 (n=250) when cefepime was reintroduced (January to September 2005). Meropenem was the alternative third-line antibiotic for all groups. Multiresistance was defined as resistance to 2 or more unrelated antibiotics, including necessarily a third or fourth generation cephalosporin, piperacillin/tazobactam or meropenem. Statistics involved Kruskal-Wallis, Mann-Whitney and logrank tests, Kaplan-Meier analysis. Groups were comparable in length of stay, time of mechanical ventilation, gestational age and birth weight. Ninety-eight Gram-negative isolates were analyzed. Patients were more likely to remain free of multiresistant isolates by Kaplan-Meier analysis in Group 2 when compared to Group 1 (p=0.017) and Group 3 (p=0.003). There was also a significant difference in meropenem resistance rates. Cefepime has a greater propensity to select multiresistant Gram-negative pathogens than piperacillin/tazobactam and should not be used extensively in neonatal intensive care.

Epidemiological Interpretation of Studies Examining the Effect of Antibiotic Usage on Resistance

“…Quasiexperimental designs in which the intervention is removed (with or without repeat intervention) also address the problem of confounding (155,156). When an outcome disappears after the intervention is removed, we are more confident of a causal relationship between the two.…”

Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us

“…These components include audits [57] , infectious disease specialist or senior clinician input [58][59][60][61][62][63][64] , or planned discontinuation/deescalation of treatment in response to clinical and microbiological outcome data [65] . Other components include rotating antibiotic schedules [57,[66][67][68][69][70] changes in prescribing policies involving antibiotic restriction, different dosing regimens or prophylaxis protocols [57,62,65,67,[71][72][73][74][75][76][77][78][79][80][81][82][83][84] and a multi-disciplinary team (MDT) approach in treatment initiation and discontinuation, often emphasising feedback and non-punitive atmosphere among staff members [83,85] . Some programmes also encompassed staff education [57,74,76] and computerised decision support platforms [86][87][88][89][90][91] .…”

Actualización en el tratamiento de la meningitis neonatal bacteriana y reporte de un caso

“…Los cultivos de LCR suelen negativizarse en un tiempo mayor que en el caso de Streptococcus del grupo B y por lo tanto cuando se asocia la enfermedad a esta bacteria su morbimortalidad es mayor (2,39). El aminoglucósido intraventricular no se usa de rutina; sin embargo, puede ser considerado en caso de ventriculitis obstructiva complicada, aunque su aprobación está en discusión.…”

“…La terapia para el Streptococcus pneumoniae se basa en el uso de penicilina (250.000 a 450.000 UI/kg/día divida en cuatro a seis fracciones) o ampicilina y cefotaxime (225-300 mg/kg/día en tres fracciones) o ceftriaxona (100mg/kg/día en una a dos tomas); si en el antibiograma no hay susceptibilidad a estos antimicrobianos se deben hacer las pruebas para valorar la sensibilidad a vancomicina (60 mg/ kg/día en cuatro fracciones), rifampicina (20mg/kg/día en dos tomas), meropenem (120 mg/kg/día en tres tomas) y cloranfenicol (75-100mg/kg/día en cuatro fracciones) (2,37,39,40).…”