Association between Vancomycin-Resistant Enterococci Bacteremia and Ceftriaxone Usage

Abstract

Objective Vancomycin-resistant Enterococci (VRE) have become a public health concern with implications for patient mortality and costs. Hospital antibiotic usage may impact VRE incidence, but the relationship is poorly understood. Animal investigations suggest ceftriaxone may be associated with VRE proliferation. We measured antimicrobial usage and VRE bloodstream infection (BSI) incidence to test our hypothesis that increased ceftriaxone use would be associated with a higher incidence of VRE-BSI. Setting The University of Alabama at Birmingham Medical Center is a 900-bed urban tertiary-care hospital Methods Retrospective analysis of antimicrobial usage and VRE-BSI from 2005 to 2008 (43 months). Antimicrobial usage quantified as days of therapy/1,000 patient-days (DOT). VRE-BSI incidence calculated as cases/1,000 patient-days. Negative binomial regression with adjustment for correlation between consecutive observations measured the association between antimicrobial usage and VRE-BSI incidence at the hospital- and care-unit levels. Results VRE-BSI incidence increased from 0.06 to 0.17 infections/1,000 patient-days. Hospital VRE-BSI incidence was associated with prior-month ceftriaxone DOT (Incidence Rate Ratio 1.38 per 10 DOT; p=0.005). After controlling for ceftriaxone, prior-month cephalosporin use (class) was not predictive of VRE-BSI (p=0.70). Similarly, prior-month use of piperacillin-tazobactam, ceftazidime, cefepime, cefazolin, or vancomycin was not predictive of VRE-BSI when considered individually (p≥0.4 for all comparisons). The final model suggests that type of intensive care unit was related to VRE-BSI incidence. Conclusions Ceftriaxone use in the prior month, but not cephalosporin (class) or vancomycin use, was related to VRE-BSI incidence. These findings suggest that an antimicrobial stewardship program that limits ceftriaxone may reduce nosocomial VRE-BSI incidence.

A Review of Combination Antimicrobial Therapy for Enterococcus faecalis Bloodstream Infections and Infective Endocarditis

“…While seemingly safe as compared to AG, safety risk associated with ceftriaxone use should not be negated. In addition to being an independent risk factor for Clostridium difficile infections [16] numerous clinical and observational studies implicate ceftriaxone as a major risk factor for occurrence of vancomycin-resistant E. faecium (VRE) infection, including bacteremia [17,18]. This is in addition to a wealth of animal studies that have linked ceftriaxone use to promotion of gastrointestinal (GI) colonization by VRE [19,20].…”

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

“…Noncontrolled usage [27] is well documented. Ceftriaxone for example, was shown to cause a rise in rates of vancomycin resistant Enterococci (VRE) rates [28] . The use of broad-spectrum antibiotics, often as the first step in therapy for patients with suspected infections, has accumulated considerable evidence regarding its association with the development of antibiotic resistance [20,26,[29][30][31][32] .…”

A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success

“…7 Inappropriate antimicrobial use is linked to the development and spread of drug-resistant pathogens, 8,9 which are associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. [1][2][3]7,8,[10][11][12][13] With antimicrobial resistance rates rising and few new antimicrobials being developed, antimicrobial stewardship programs are increasingly employed as a key strategy for optimizing antimicrobial prescribing in a variety of patient care settings. [1][2][3][14][15][16][17] "Antimicrobial stewardship" is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities.…”