Impact of Antibiotic Use during Hospitalization on the Development of Gastrointestinal Colonization with Escherichia coli with Reduced Fluoroquinolone Susceptibility

Abstract

OBJECTIVE Infections due to fluoroquinolone-resistant Escherichia coli (FQREC) are associated with significant morbidity and mortality. Fluoroquinolone resistance likely arises at the level of gastrointestinal colonization. The objective of this study was to identify risk factors for the development of FQREC gastrointestinal tract colonization in hospitalized patients, including the impact of antibiotics prescribed during hospitalization. DESIGN A prospective cohort study was conducted from 2002 to 2004 within a university health system. METHODS Hospitalized patients initially colonized with fluoroquinolone-susceptible E. coli were followed up with serial fecal sampling for new FQREC colonization or until hospital discharge or death. A Cox proportional hazards regression model was developed to identify risk factors for new FQREC colonization, with antibiotic exposure modeled as time-varying covariates. RESULTS Of 395 subjects, 73 (18.5%) became newly colonized with FQREC. Length of stay before sampling (hazard ratio [HR], 1.02 [95% confidence interval (CI), 1.1–1.03]; P = .003) and malignancy (HR, 0.37 [95% CI, 0.21–0.67]; P = .001) were significantly associated with the development of FQREC colonization. In addition, receipt of a first-generation cephalosporin (HR, 1.19 [95% CI, 1.10–1.29]; P < .001) or cefepime (HR, 1.05 [95% CI, 1.00–1.10]; P = .048) during hospitalization increased the risk of new FQREC colonization. CONCLUSIONS The acquisition of FQREC in the hospital setting is complex, and antimicrobial stewardship programs should take into account patterns of antibiotic use in implementing strategies to reduce the development of new FQREC colonization. Future studies are needed to identify risk factors for infection in hospitalized patients newly colonized with FQREC.

Drug-resistant Enterobacteriaceae colonization is associated with healthcare utilization and antimicrobial use among inpatients in Pune, India

“…Unfettered antibiotic use has been implicated as one of the key factors driving global increasing antimicrobial resistance [ 1 ]. Studies in other settings have demonstrated that antibiotic administration and ICU admission are associated with development of antibiotic-resistant bacterial stool colonization during the course of a hospitalization, but used longer intervals between enrollment and follow-up [ 28 , 36 ]. The finding that initial empiric antibiotic choice can also significantly impact this process is concerning, especially given how commonly third generation cephalosporins are used in India and elsewhere.…”

Outpatient Antibiotic Prescription

“…The potentially adverse consequences of increased prescriptions of cephalosporins rather than oral penicillin and amoxicillin are sufficiently demonstrated for the outpatient sector in our view, especially with regard to antibiotic-associated Clostridium difficile infections (24)(25)(26)(27). Data for selection of gram-negative bacteria that are extended-spectrum beta-lactamase (ESBL)-positive or otherwise resistent to cephalosporins are less certain but still plausible (28)(29)(30)(31).…”

Risk factors for quinolone-resistant Escherichia coli infection: a systematic review and meta-analysis

“…However, some studies did change the pooled results. Specifically, when we removed the studies of Han et al, [34] the heterogeneities for cancer and cardiovascular disease were distinctly reduced evidently by I 2 decreased from 75 to 40% and from 69 to 46%, respectively. After using a fixed-effects model, the ORs and the corresponding 95% CIs for cancer changed from 1.66 (0.96, 2.85) to 2.07 (1.57, 2.75) and from 1.76 (1.02, 3.04) to 2.28 (1.66, 3.12).…”