Outcome Variations Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit.
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Summary
Posted By:	Gordon S. Doig
E-Mail:	Gordon.Doig@EvidenceBased.net
Posted Date:	3 June 2005
Title:	Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit.
Authors:	Aubert G, Carricajo A, Vautrin AC, Guyomarc'h S, Fonsale N, Page D, Brunel P, Rusch P, Zeni F.
Reference:	J Hosp Infect. 2005 Feb;59(2):83-9.
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Abstract:	The purpose of this study was to assess the effect of reducing prescription of fluoroquinolones in an intensive care unit (ICU) upon bacterial resistance, particularly as regards Pseudomonas aeruginosa. For six months between January 2001 and June 2001, administration of fluoroquinolones was kept to a minimum. A bacteriological screening of patients was performed to assess the incidence of fluoroquinolone-resistant bacteria. There was a 75.8% restriction in prescriptions of fluoroquinolones. There was no significant change in bacterial ecology between the periods preceding (12 months) and following (12 months) restriction. There was a significant recovery of sensitivity of P. aeruginosa to ciprofloxacin (P lte 0.01), with a decrease in resistant strains from 71.3% in the pre-restriction period to 52.4% in the post-restriction period. Regarding clinical data, no significant differences were noted between the pre-restriction and the post-restriction periods, except for the number of cases of ventilator-associated pneumonia with P. aeruginosa resistant to ciprofloxacin. This study demonstrated the possibility of introducing rotation of antibiotics in an ICU.
Are the recommendations valid?
1. Are the outcome measures accurate and comprehensive?
	The authors report sensitivity of P. aeruginosa to cirprofloxicin as their primary outcome however it is not entirely clear whether surveillance cultures or culture results based on a clinical suspician of infection were used. Differentiation of the two types might have been extremely useful since some patients were admitted to the ICU with cipro-resistant P aeruginosa. Subesequent surveillance cultures from these patients are not likely to be as meaningful as new cultures. They also report the proprotion of micro-confirmed VAP cases with P. aeruginsa, mortality of pts with VAP, ICU LoS and ICU mortality. The outcome list is fairly comprehensive.
2. Were the comparison groups similar with respect to important determinants of outcome, other than the one of interest, and were residual differences adjusted for in the analysis?
2a. Did the investigators measure all known important prognostic factors?
	The authors measured the number of pts admitted to the ICU with positive surveillance cultures for cipro-resistant P. aeruginosa. They also collected general ICU severity scores and reported ICU LoS and the number of pts requiring IMV > 48hrs. These are all probably reasonable risk factors for subsequent infection. The authors do not report whether these measures are validated risk factors for infection.
2b. Were measures of patients' prognostic factors reproducible and accurate?
	The majority of the risk factors collected are objective and repeatable.
2c. Did the investigators show the extent to which patients differed on these factors?
	Yes. Table II provides a description of the patients admitted to the ICU during the three study periods based on the above parameters.
2d. Did the researchers use some form of multivariate analysis to adjust for all the important prognostic factors?
	No. The investigators do not conduct any form of multivariate analysis to determine if changes in risk factors could explain the changes seen in the primary outcome.
2e. Did additional analyses (particularly in low-risk subgroups) demonstrate the same results as the primary analysis?
	No. The authors did not show culture rates from high risk or low risk patients.
What are the recommendations?
1. What are the recommendations?
	"This study demonstates the possibility of introducing rotation of antibiotics in the ICU."
Will the recommendations help you in caring for your patients?
1. How will the recommendations help you?
	Yes. If resistance develops as a result of relaxing our fluoroquinolone use policy, it can be addressed by making the policy more restrictive again.
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