Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis

Abstract

Background: Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile. Methods: We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care−associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis. Results: The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days −15.3, P < .01). The health care−associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile. Conclusions: Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.

Effects of Fluoroquinolone Restriction In the hospital on the Development Of sensitivity of Selected Bacterial Pathogens

“…The present study included strains mainly from hospitalized patients (from all wards), but a portion of strains (primarily E .coli and S. aureus), was of a community origin. A similar relationship of strains was also found in the study by Hecker, where a 30% share of E. coli was obtained from hospitalized patients (Hecker et al 2019). The strains from a community are not influenced by decreased consumptions of antibiotics in the hospital and their share may thus distort the results of the study.…”

“…None of these increases was, nevertheless, statistically significant. In the study of Hecker, investigating the syndrome impact of specific measures on fluoroquinolones consumption, sensitivity to fluoroquinolones was significantly increased in P. aeruginosa 75-84%, but not in E. coli (84-85%) or K. pneumoniae (Hecker et al 2019). Increased sensitivity to P. aeruginosa has been confirmed also by other studies -during a ten-year period an increase by 16% (Lafaurie et al 2012), by 18.4% in 6 months (Aubert et al 2005), and also by others (O´Brien et al 2015, Wu et al 2011).…”

Efficacy of a stewardship intervention focused on reducing unnecessary use of non–Clostridioides difficile antibiotics in patients with Clostridioides difficile infection

“…Third, the intervention was quasi-experimental and was conducted in a facility with a well-established antimicrobial stewardship program including ongoing efforts to reduce treatment of asymptomatic bacteriuria and minimize overuse of fluoroquinolones. 10 Fourth, the primary intervention occurred at the time of CDI diagnosis with less feedback after completion of CDI treatment, particularly in outpatients. Finally, bivariate analyses were conducted without correction for multiple comparisons.…”

Impact of Reduced Fluoroquinolone Use on Clostridioides difficile Infections Resulting From the Fluoroquinolone-Resistant Ribotype 027 Strain in a Veterans Affairs Medical Center

“…To estimate the percentage of HCFA CDI cases due to the 027 strain, we cultured the first 5 individual patient stool specimens from each quarter of the year (a total of 20 per year) from 2009 through 2018 for toxigenic C. difficile [5, 7]. PCR ribotyping using capillary gel electrophoresis and fluorescent ribotyping was performed as previously described [5]. All isolates were tested for moxifloxacin susceptibility by broth dilution minimum inhibitory concentrations (MIC).…”

“…However, fluoroquinolone restriction has not always been similarly effective. For example, in a tertiary care hospital a significant reduction in fluoroquinolone prescribing did not reduce CDI or the proportion of cases due to 027 strains [5].…”