Impact of Combination Antibiogram and Related Education on Inpatient Fluoroquinolone Prescribing Patterns for Patients With Health Care–Associated Pneumonia

Liang, Baoqi; Wheeler, James; Blanchette, Lisa M.

doi:10.1177/1060028015625658

Cited by 14 publications

(6 citation statements)

References 20 publications

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“…Ciprofloxacin-based combinations performed particularly poorly, with the rates of susceptibility of this resistant subgroup being only 75 to 81%. This observed inferiority of fluoroquinolone-based combinations compared to aminoglycoside-based regimens is in line with previous data, with ␤-lactam-fluoroquinolone cross-resistance being more common than ␤-lactam-aminoglycoside cross-resistance (26,27). This is a limitation of standard antibiograms, which do not account for cross-resistance and may cause clinicians to overestimate the effectiveness of dual therapy.…”

Section: Discussionsupporting

confidence: 87%

“…This is a limitation of standard antibiograms, which do not account for cross-resistance and may cause clinicians to overestimate the effectiveness of dual therapy. Combination antibiograms, which report in vitro suscep- tibilities to the select antibiotic combinations, may be of enhanced utility when dual therapy is being considered by providing a more accurate picture of the expected benefit (27). Although these data imply that tobramycin-based combination regimens should be preferred, it must be considered that patients with ␤-lactam-resistant, tobramycin-susceptible isolates would essentially be treated only with an aminoglycoside, at least until the final reporting of susceptibilities.…”

Section: Discussionmentioning

confidence: 99%

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In Vitro Comparison of Ceftolozane-Tazobactam to Traditional Beta-Lactams and Ceftolozane-Tazobactam as an Alternative to Combination Antimicrobial Therapy for Pseudomonas aeruginosa

Goodlet

Nicolau

Nailor

2017

Antimicrob Agents Chemother

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Guidelines for the treatment of sepsis, febrile neutropenia, and hospitalacquired pneumonia caused by Pseudomonas aeruginosa include empirical regimens incorporating two antibiotics from different classes with activity against P. aeruginosa for select at-risk patients to increase the likelihood that the organism will be susceptible to at least one agent. The activity against P. aeruginosa and the rates of cross-resistance of ceftolozane-tazobactam were compared to those of the ␤-lactam comparators cefepime, ceftazidime, piperacillin-tazobactam, and meropenem alone and cumulatively with ciprofloxacin or tobramycin. Nonurine P. aeruginosa isolates were collected from adult inpatients at 44 geographically diverse U.S. hospitals. MICs were determined using reference broth microdilution methods. Of the 1,257 isolates collected, 29% were from patients in intensive care units and 39% were from respiratory sites. The overall rate of susceptibility to ceftolozane-tazobactam was high at 97%, whereas it was 72 to 76% for cefepime, ceftazidime, piperacillin-tazobactam, and meropenem. The rate of nonsusceptibility to all four comparator ␤-lactams was 11%; of the isolates nonsusceptible to the four comparator ␤-lactams, 80% remained susceptible to ceftolozane-tazobactam. Among the isolates nonsusceptible to the tested ␤-lactam comparators, less than half were susceptible to ciprofloxacin. By comparison, approximately 80% of the ␤-lactam-nonsusceptible isolates were susceptible to tobramycin, for overall cumulative susceptibility rates of 94 to 95%, nearly 10% higher than that of the ciprofloxacin-␤-lactam combinations and approaching that of ceftolozane-tazobactam as a single agent. The rates of susceptibility to ceftolozane-tazobactam were consistently high, with little observable crossresistance. Ceftolozane-tazobactam monotherapy performed at or above the level of commonly utilized combination therapies on the basis of in vitro susceptibilities. Ceftolozane-tazobactam should be considered for use in patients at high risk for resistant P. aeruginosa infection and as an alternative to empirical combination therapy, especially for patients unable to tolerate aminoglycosides.KEYWORDS Pseudomonas aeruginosa, antimicrobial resistance, ceftolozanetazobactam, combination treatment, resistance P seudomonas aeruginosa is a notorious cause of nosocomial infection both within the United States and around the world. The CDC's National Healthcare Safety Network lists P. aeruginosa as the seventh most common cause of health careassociated infection, accounting for 8% of all reported cases (1), while other surveillance

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

In Vitro Comparison of Ceftolozane-Tazobactam to Traditional Beta-Lactams and Ceftolozane-Tazobactam as an Alternative to Combination Antimicrobial Therapy for Pseudomonas aeruginosa

Goodlet

Nicolau

Nailor

2017

Antimicrob Agents Chemother

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“…The results of this study offer insights into the utility of combination antibiograms as tools for informed antimicrobial prescribing in hospitals [29]. However, we caution antimicrobial stewardship programs to selectively report combination antibiograms for bacteria only in settings where it would be clinically useful in order to minimize misuse and misinterpretation.…”

Section: Discussionmentioning

confidence: 99%

Utility of Combination Antimicrobial Therapy in Adults with Bloodstream Infections due to Enterobacteriaceae and Non-Fermenting Gram-Negative Bacilli Based on In Vitro Analysis at Two Community Hospitals

et al. 2019

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This study examined the utility of combination therapy for bloodstream isolates of Enterobacteriaceae and non-fermenting Gram-negative bacilli (NFGN) from adults at two community hospitals from January 2010 through to June 2015. Changes to in vitro antimicrobial susceptibilities by adding ciprofloxacin or gentamicin to third-generation cephalosporins (3GC) were examined overall and in patients with risk factors for 3GC resistance. Overall ceftriaxone susceptibility among Enterobacteriaceae was 996/1063 (94%) and 247/295 (84%) in patients with 3GC resistance risk factors. Susceptibilities increased marginally by adding ciprofloxacin or gentamicin (mean difference 2.4% (95% CI 1.5, 3.4) and 3.0% (95% CI 2.0, 4.0), respectively, overall and 5.4% (95% CI 2.8, 8.0) and 7.1% (95% CI 4.2, 10.1), respectively, in patients with risk factors). Eighty-three of 105 (79%) NFGN were susceptible to ceftazidime overall and 20/29 (69%) in patients with prior beta-lactam use. Overall mean increase in susceptibilities was 15.2% (95% CI: 8.3, 22.2) and 17.1% (95% CI: 9.8, 24.5) for ciprofloxacin and gentamicin combinations, respectively; and 27.6% (95% CI: 10.3, 44.9) for either one with recent beta-lactam use. In this setting, empirical combination therapy had limited utility for Enterobacteriaceae bloodstream isolates but provided significant additional antimicrobial coverage to ceftazidime for NFGN, particularly in patients with prior beta-lactam use.

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“…This is particularly the case for acute medical patients presenting with a spectrum of symptoms that could possibly be indicative of infection. This initial decision could be supported by guidelines and anti-biograms (Liang et al, 2016) where available, and subsequently be refined based on microbiological results or review as part of a hospital's stewardship programme. For individual physicians, however, making these initial treatment decisions under conditions of uncertainty often involves balancing risks; their views about what constitutes the "correct" or most appropriate course of action may differ.…”

Section: Introductionmentioning

confidence: 99%

Moral and Contextual Dimensions of “Inappropriate” Antibiotic Prescribing in Secondary Care: A Three-Country Interview Study

et al. 2020

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Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used "incorrectly" (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.

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Impact of Combination Antibiogram and Related Education on Inpatient Fluoroquinolone Prescribing Patterns for Patients With Health Care–Associated Pneumonia

Abstract: Facility-specific combination antibiograms may be used to inform antibiotic prescribing in HCAP patients.

Cited by 14 publications

References 20 publications

In Vitro Comparison of Ceftolozane-Tazobactam to Traditional Beta-Lactams and Ceftolozane-Tazobactam as an Alternative to Combination Antimicrobial Therapy for Pseudomonas aeruginosa

In Vitro Comparison of Ceftolozane-Tazobactam to Traditional Beta-Lactams and Ceftolozane-Tazobactam as an Alternative to Combination Antimicrobial Therapy for Pseudomonas aeruginosa

Utility of Combination Antimicrobial Therapy in Adults with Bloodstream Infections due to Enterobacteriaceae and Non-Fermenting Gram-Negative Bacilli Based on In Vitro Analysis at Two Community Hospitals

Moral and Contextual Dimensions of “Inappropriate” Antibiotic Prescribing in Secondary Care: A Three-Country Interview Study

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