Impact of a restrictive antibiotic policy on the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in an endemic region: a before-and-after, propensity-matched cohort study in a Caribbean intensive care unit

Abstract

Background High-level antibiotic consumption plays a critical role in the selection and spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) in the ICU. Implementation of a stewardship program including a restrictive antibiotic policy was evaluated with respect to ESBL-E acquisition (carriage and infection). Methods We implemented a 2-year, before-and-after intervention study including all consecutive adult patients admitted for > 48 h in the medical-surgical 26-bed ICU of Guadeloupe University Hospital (French West Indies). A conventional strategy period (CSP) including a broad-spectrum antibiotic as initial empirical treatment, followed by de-escalation (period before), was compared to a restrictive strategy period (RSP) limiting broad-spectrum antibiotics and shortening their duration. Antibiotic therapy was delayed and initiated only after microbiological identification, except for septic shock, severe acute respiratory distress syndrome and meningitis (period after). A multivariate Cox proportional hazard regression model adjusted on propensity score values was performed. The main outcome was the median time of being ESBL-E-free in the ICU. Secondary outcome included all-cause ICU mortality. Results The study included 1541 patients: 738 in the CSP and 803 in the RSP. During the RSP, less patients were treated with antibiotics (46.8% vs. 57.9%; p < 0.01), treatment duration was shorter (5 vs. 6 days; p < 0.01), and administration of antibiotics targeting anaerobic pathogens significantly decreased (65.3% vs. 33.5%; p < 0.01) compared to the CSP. The incidence of ICU-acquired ESBL-E was lower (12.1% vs. 19%; p < 0.01) during the RSP. The median time of being ESBL-E-free was 22 days (95% CI 16-NA) in the RSP and 18 days (95% CI 16–21) in the CSP. After propensity score weighting and adjusted analysis, the median time of being ESBL-E-free was independently associated with the RSP (hazard ratio, 0.746 [95% CI 0.575–0.968]; p = 0.02, and hazard ratio 0.751 [95% CI 0.578–0.977]; p = 0.03, respectively). All-cause ICU mortality was lower in the RSP than in the CSP (22.5% vs. 28.6%; p < 0.01). Conclusions Implementation of a program including a restrictive antibiotic strategy is feasible and is associated with less ESBL-E acquisition in the ICU without any worsening of patient outcome.

High Prevalence of blaCTXM–1/IncI1-Iγ/ST3 Plasmids in Extended-Spectrum β-Lactamase-Producing Escherichia coli Isolates Collected From Domestic Animals in Guadeloupe (French West Indies)

“…The overall prevalence of ESBL-E rectal carriage in pets (4.7%, 95% CI: 2.1–9.1) was moderate, in agreement with observations of fecal carriage among pigs (7.3%), beef cattle (14.7%) and humans (4.4%) in Guadeloupe ( Gruel et al, 2021 ; Le Terrier et al, 2021 ). The prevalence of ESBL-E carriage was in the range observed worldwide (average, 6.9%) in a meta-analysis, the highest level being reported in dogs in Africa (16.5%) and in cats in Asia (16.8%) ( Salgado-Caxito et al, 2021 ).…”

“…Data on resistance to antibiotics in Guadeloupe are scarce and recent. The University Hospital of Guadeloupe faced the emergence of carbapenemase-producing Enterobacteriaceae isolates and a very high incidence of nosocomial ESBL-E infections ( Bastian et al, 2015 ; Breurec et al, 2015 ; Le Terrier et al, 2021 ). A moderate prevalence of ESBL-E (around 5%) was observed in studies on community human urinary tract infections ( Guyomard-Rabenirina et al, 2016 ), on fecal carriage by domestic animals and livestock ( Gruel et al, 2021 ) and on wild fauna ( Guyomard-Rabenirina et al, 2020 ).…”

Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial

“…Generally, ICUs are among the heaviest consumers of antibiotics, with an estimated 70% of patients receiving antibiotics during an ICU stay ( 7 ). Various observational and before-after studies show that duration of antibiotic therapy is linked to antibiotic resistance development, both in ICU ( 17 , 18 ) and non-ICU ( 19 – 21 ) settings. A number of randomized trials have shown that targeted interventions can safely reduce the ABTD in ICU ( 11 , 22 , 23 ) or non-ICU ( 9 , 10 , 12 , 13 ) patients.…”

Potential of Multiplex Polymerase Chain Reaction Performed on Protected Telescope Catheter Samples for Early Adaptation of Antimicrobial Therapy in ARDS Patients

“…However, in the recent surviving sepsis campaign guidelines, in adults with possible sepsis and not in shock, a time-limited, rapid investigation is advised [ 16 ]. Moreover, recent studies have shown that an antibiotic stewardship program that initiates antibiotic therapy only after microbiological identification, except for septic shock or severe ARDS, is safe [ 17 ]. As evidenced, mPCR results were obtained a couple of hours after sampling; therefore, intensivists could wait for such results to optimize antibiotic prescription.…”