THE IMPACT OF ANTIMICROBIAL USE ON THE EMERGENCE OF ANTIMICROBIAL-RESISTANT BACTERIA IN HOSPITALS
Section snippets
BIOLOGIC MODEL
A clear relationship between antimicrobial use and resistance has been shown by a biologic model. Developed by Levy et al, this animal model for selection and dissemination of tetracycline-resistant Escherichia coli in chickens receiving oxytetracycline-supplemented feed showed a strong relationship between the introduction of the antimicrobial and development of resistance.20 Other studies have found that antimicrobial resistance among pathogens isolated from humans quickly followed the
THE IMPORTANCE OF THE HOSPITAL ENVIRONMENT
Most,4, 16, 35 but not all,22 studies suggest that resistance is greater among pathogens isolated from hospitalized patients than among those isolated from patients in the community. In a multicenter study, Project ICARE (Intensive Care Antimicrobial Resistance Epidemiology), implemented in 1994 by the CDC and the Rollins School of Public Health, Emory University, information from microbiology laboratories was collected from eight US hospitals.25 These hospitals reported nosocomial infections,
THE SIGNIFICANCE OF THE INTENSIVE CARE UNIT
The higher rates among isolates from ICUs is reflected in many studies.4, 13, 16, 35 The reasons for the higher percentage vary. Factors that might increase the risk for antimicrobial resistance in hospitalized patients, and ICU patients in particular, include cross-transmission of pathogens between closely quartered patients, lack of asepsis during crisis care, transfer of patients colonized with resistant pathogens between units or other hospitals, or introduction of resistant organisms from
PREVALENCE OF ANTIMICROBIAL USE IN HOSPITALS
Perhaps no other factor is more important in the development of antimicrobial resistance than antimicrobial use in hospitals. Approximately 25% to 40% of all hospitalized patients receive antimicrobials.8, 9, 12, 19, 23, 30, 31 Among ICU patients and surgical patients the percentage is even higher. Many antimicrobials are used only or primarily in hospitals. Doses of antimicrobials often are higher in hospitals, especially with parenteral administration. This higher dosing creates a strong
CHANGES IN ANTIMICROBIAL USE LEADING TO CHANGES IN ANTIMICROBIAL RESISTANCE
Most hospitals involved in the collection of the aminoglycoside resistance/use data collection found that changes in antimicrobial use led to parallel changes in resistance.17 The National Nosocomial Resistance Surveillance Group found similar parallels but also found that the relationship was not necessarily maintained for all antimicrobial/pathogen combinations.3 For example, for ceftazidime use a linear relationship between use and resistance was apparent for ceftazidime-resistant
OPTIMIZING USE OF ANTIMICROBIALS
There were striking differences between Project ICARE hospitals in Phase 2 among the amounts of antimicrobials used. Table 1 shows the use of the antistaphylococcal penicillins, first-generation cephalosporins, vancomycin, ceftazidime, third-generation cephalosporins, and fluoroquinolones from Phase 2 of Project ICARE. Although the data are preliminary, three of the 41 hospitals submitting ICARE data on antimicrobial use were consistently among the highest users for a variety of antimicrobial
EXAMINING ANTIMICROBIAL USE IN A HOSPITAL
If an institution determines that it is overusing antimicrobials with comparative data such as those provided by Project ICARE, a close examination of the patterns of antimicrobial use is needed. Studies suggest that antimicrobial use can be divided into three categories: empiric therapy, definitive therapy, and prophylaxis. Surprisingly, only about 30% of all antimicrobials in hospitals are used for definitive therapy where the susceptibility patterns for the infection-associated pathogen are
CONCLUSIONS
Several considerations must be kept in mind when evaluating antimicrobial resistance and use in hospitals. Interpretation of the magnitude of antimicrobial resistance in hospitals cannot be made without knowledge of a hospital's pattern of antimicrobial use. Because the ICU is often the focus of resistance in a hospital, the ICU and non-ICU inpatient areas should be examined separately. Dramatic differences exist in patterns of antimicrobial resistance and use in hospitals. In particular, a
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Address reprint requests to Robert Gaynes, MD, Hospital Infections Program, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-55, Atlanta, GA 30333
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From the Nosocomial Infections Surveillance Activity, Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta, Georgia