Effect of antibiotic stewardship interventions in primary care on antimicrobial resistance of Escherichia coli bacteraemia in England (2013–18): a quasi-experimental, ecological, data linkage study

Abstract

Background Antimicrobial resistance is a major global health concern, driven by overuse of antibiotics. We aimed to assess the effectiveness of a national antimicrobial stewardship intervention, the National Health Service (NHS) England Quality Premium implemented in 2015-16, on broad-spectrum antibiotic prescribing and Escherichia coli bacteraemia resistance to broad-spectrum antibiotics in England.Methods In this quasi-experimental, ecological, data linkage study, we used longitudinal data on bacteraemia for patients registered with a general practitioner in the English National Health Service and patients with E coli bacteraemia notified to the national mandatory surveillance programme between Jan 1, 2013, and Dec 31, 2018. We linked these data to data on antimicrobial susceptibility testing of E coli from Public Health England's Second-Generation Surveillance System. We did an ecological analysis using interrupted time-series analyses and generalised estimating equations to estimate the change in broad-spectrum antibiotics prescribing over time and the change in the proportion of E coli bacteraemia cases for which the causative bacteria were resistant to each antibiotic individually or to at least one of five broad-spectrum antibiotics (co-amoxiclav, ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin), after implementation of the NHS England Quality Premium intervention in April, 2015.Findings Before implementation of the Quality Premium, the rate of antibiotic prescribing for all five broad-spectrum antibiotics was increasing at rate of 0•2% per month (incidence rate ratio [IRR] 1•002 [95% CI 1•000-1•004], p=0•046). After implementation of the Quality Premium, an immediate reduction in total broad-spectrum antibiotic prescribing rate was observed (IRR 0•867 [95% CI 0•837-0•898], p<0•0001). This effect was sustained until the end of the study period; a 57% reduction in rate of antibiotic prescribing was observed compared with the counterfactual situation (ie, had the Quality Premium not been implemented). In the same period, the rate of resistance to at least one broad-spectrum antibiotic increased at rate of 0•1% per month (IRR 1•001 [95% CI 0•999-1•003], p=0•346). On implementation of the Quality Premium, an immediate reduction in resistance rate to at least one broad-spectrum antibiotic was observed (IRR 0•947 [95% CI 0•918-0•977], p=0•0007). Although this effect was also sustained until the end of the study period, with a 12•03% reduction in resistance rate compared with the counterfactual situation, the overall trend remained on an upward trajectory. On examination of the long-term effect following implementation of the Quality Premium, there was an increase in the number of isolates resistant to at least one of the five broadspectrum antibiotics tested (IRR 1•002 [1•000-1•003]; p=0•047).Interpretation Although interventions targeting antibiotic use can result in changes in resistance over a short period, they might be insufficient alone to curtail antimicrobial resistance.

Effect of Fluoroquinolone Use in Primary Care on the Development and Gradual Decay of Escherichia coli Resistance to Fluoroquinolones: A Matched Case-Control Study

“…In contrast to the approach used in the latter and in other studies, e.g., as in Cuevas et al [ 16 ], we were able to quantify the impact on resistance of previous antibiotic use at an individual level, avoiding the risk of the so-called ecological fallacy. Some studies, also mostly ecological, showed persistent bacterial resistance despite reduced antibiotic use in E. coli and in other species [ 17 , 18 ], while other studies showed the opposite [ 10 , 19 , 20 ]. A possible explanation of these divergent findings is likely the fact that bacterial resistance is a complex phenomenon, with primary care prescribing being only one of its drivers [ 21 ].…”

Antibiotic Resistance and Mechanisms of Pathogenic Bacteria in Tubo-Ovarian Abscess

“…Among the 134 E. coli isolates collected from Hangzhou nosocomial bloodstream infections from 2013 to 2016, approximately 41.5% were identified as extended-spectrum blactamase (ESBL)-producing-positive by Jiang et al (2019). Even though medical institutions have imposed strict controls and rules on the use of antibiotics, publications suggest that the growing trend of drug resistance in E. coli continues (Aliabadi et al, 2021).…”

“…(2019) . Even though medical institutions have imposed strict controls and rules on the use of antibiotics, publications suggest that the growing trend of drug resistance in E. coli continues ( Aliabadi et al., 2021 ).…”

Acacia Fiber Protects the Gut from Extended-Spectrum Beta-Lactamase (ESBL)-Producing Escherichia coli Colonization Enabled by Antibiotics

“…( 21 ). As stewardship alone has been insufficient at slowing the spread of ESBL-producing E. coli ( 22 ), it is imperative to determine the drivers of its increasing colonization. Here, we developed a murine model in which mice were exposed to different antibiotics under various conditions to determine protective and antiprotective factors that altered pathogenic E. coli colonization persistence.…”