Class Restriction of Cephalosporin Use to Control Total Cephalosporin Resistance in Nosocomial Klebsiella

• Published in: JAMA : the journal of the American Medical Association Vol. 280; no. 14; pp. 1233 - 1237
• Main Authors: Rahal, James J, Urban, Carl, Horn, David, Freeman, Katherine, Segal-Maurer, Sorana, Maurer, James, Mariano, Noriel, Marks, Sheila, Burns, Janice M, Dominick, Dana, Lim, Mimi
• Format: Journal Article
• Language: English
• Published: Chicago, IL American Medical Association 14.10.1998
• Subjects: Adult; Antibacterial agents; Antibiotics; Antibiotics. Antiinfectious agents. Antiparasitic agents; Bacteria; Biological and medical sciences; Cephalosporin Resistance; Cephalosporins - therapeutic use; Cross Infection - epidemiology; Cross Infection - prevention & control; Drug resistance; Drug Resistance, Microbial; Drug therapy; Drug Utilization Review - statistics & numerical data; Guideline Adherence; Hospital Bed Capacity, 500 and over; Hospitals, Community; Humans; Imipenem - pharmacology; Incidence; Infection Control; Klebsiella; Klebsiella - drug effects; Klebsiella Infections - epidemiology; Klebsiella Infections - prevention & control; Medical research; Medical sciences; New York City - epidemiology; Pharmacology. Drug treatments; Pseudomonas aeruginosa - drug effects; Pseudomonas Infections - epidemiology; Thienamycins - pharmacology; USA, New York, Queens; New York City; Human; Klebsiella; Nosocomial infection; Pharmacology; Incidence; Infection; Restriction modification; Antibiotic; Carbapenem derivatives; Cephalosporin derivatives; Bacteriosis; Bacteria; Clinical investigation; Antibacterial agent; Pharmacokinetics; Negative therapeutic reaction; Comparative study; Enterobacteriaceae; Imipenem
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.280.14.1233

CONTEXT.— Resistance to most or all cephalosporin antibiotics in Klebsiella species has developed in many European and North American hospitals during the past 2 decades. OBJECTIVE.— To determine if restriction of use of the cephalosporin class of antibiotics would reduce the incidence of patient infection or colonization by cephalosporin-resistant Klebsiella. DESIGN.— A before-after comparative 2-year trial. SETTING.— A 500-bed, university-affiliated community hospital in Queens, NY. PATIENTS.— All adult medical and surgical hospital inpatients. INTERVENTION.— A new antibiotic guideline excluded the use of cephalosporins except for pediatric infection, single-dose surgical prophylaxis, acute bacterial meningitis, spontaneous bacterial peritonitis, and outpatient gonococcal infection. All other cephalosporin use required prior approval by the infectious disease section. MAIN OUTCOME MEASURE.— Incidence of patient infection or colonization by ceftazidime-resistant Klebsiella during 1995 (control period) compared with 1996 (intervention period). RESULTS.— An 80.1% reduction in hospital-wide cephalosporin use occurred in 1996 compared with 1995. This was accompanied by a 44.0% reduction in the incidence of ceftazidime-resistant Klebsiella infection and colonization throughout the medical center (P<.01), a 70.9% reduction within all intensive care units (P<.001), and an 87.5% reduction within the surgical intensive care unit (P<.001). A concomitant 68.7% increase in the incidence of imipenem-resistant Pseudomonas aeruginosa occurred throughout the medical center (P<.01). All such isolates except one were susceptible to other antibiotics. CONCLUSION.— Extensive cephalosporin class restriction significantly reduced nosocomial, plasmid-mediated, cephalosporin-resistant Klebsiella infection and colonization. This occurred at the price of increased imipenem resistance in P aeruginosa, which remained susceptible to other agents. Thus, an overall reduction in multiply-resistant pathogens was achieved within 1 year.