October 6, 2011 (Chicago, Illinois) — An on-site infectious disease consultation service at a Veterans Affairs (VA) long-term care facility led to a significant decrease in the overall use of antimicrobials, oral agents, and especially fluoroquinolones.
Robin Jump, MD, PhD, from the Louis Stokes Cleveland VA Medical Center in Ohio, presented the data to delegates here at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy.
Total days of use of oral or intravenous antibiotics decreased by a significant 11%. There was a shift toward the use of narrower-spectrum β-lactam antibiotics, but the use of third- and fourth-generation cephalosporins also increased, Dr. Jump reported.
The investigators note that half to three quarters of residents of long-term care facilities receive antibiotics each year, and 25% to 75% of these courses might be unnecessary. However, because of the limited availability of expert personnel and diagnostic facilities to properly evaluate patients for suspected infections, antibiotics are likely being prescribed inappropriately, leading to antibiotic overuse.
The researchers sought to determine whether an on-site infectious disease consultation service would lower the use of oral antimicrobial drugs and shift use from broad-spectrum to narrow-spectrum agents. By comparing antimicrobial use for 18 months before and after the implementation of the service, they were able to detect shifts in drug use, expressed as days of therapy per 1000 patient-days (DOT/1000 PD).
Narrow-Spectrum Antibiotic Use Jumped
Dr. Jump reported that the use of fluoroquinolones dropped by 40%, from 37 to 22 DOT/1000 PD (P < .0001). The use of piperacillin-tazobactam also decreased by 40% (7.0 to 4.2 DOT/1000 PD; P < .0001). At the same time, a dramatic increase — of 247% — occurred in the use of ampicillin-sulbactam, a narrower-spectrum drug combination (from 0.7 to 4.2 DOT/1000 PD; P < .0001).
Although the use of first-generation cephalosporins decreased, Dr. Jump said her group saw an unexpected 26% increase in the administration of third- and fourth-generation cephalosporins (5.9 to 7.9 DOT/1000 PD; P < .0001).
While the total use of oral agents decreased by 24% (116 to 88 DOT/1000 PD; P < .0001), total intravenous drug use increased by 30% (39 to 51 DOPT/1000 PD; P < .0001). Overall, the researchers found an 11% decrease in total antibiotic administration after the service was implemented (155 vs 139 DOT/1000 PD; P < .0001).
Dr. Jump concluded that the service was associated with a significant decrease in total antimicrobial use. The greatest effect seen was for fluoroquinolones, but other oral agents were also affected. The findings suggest that the service led to better antibiotic stewardship.
Session moderator Stephan Harbarth, MD, MS, associate professor, attending physician in infectious diseases, and associate hospital epidemiologist at Geneva University Hospitals in Switzerland, told Medscape Medical News that it is good to see a large decrease in the use of fluoroquinolones.
"In the United States, fluoroquinolones are heavily overused," Dr. Harbarth said. "It's one of the biggest problems in the United States.... They are used in many indications where in Europe we would use alternative agents."
It is possible that the large increase in the use of ampicillin-sulbactam resulted from the common practice of empiric treatment of infections, especially respiratory tract infections, in long-term care facilities because of a lack of microbiology support.
The study did not report on clinical outcomes or costs associated with the infectious disease consultation service. With many broad-spectrum antibiotics becoming available in generic form, Dr. Harbarth said, they are becoming very inexpensive. "So if you only look at the cost of this kind of program — paying an infectious disease physician in a long-term care facility to have a partial consultation role — compared with the cost of antibiotics, it may not be cost beneficial." However, he said, a similar program in Geneva has demonstrated cost benefits.
Antibiotics and professional services are not the only contributors to overall cost. "For instance, you have less resistance and therefore spend much less on specific infection-control measures, or you can control antifungals, which are very expensive at the moment," Dr. Harbarth said.
"Antibiotic stewardship, from a longer-term perspective, should not only be cost-driven. There are many other issues that have to be taken into consideration — adverse outcomes, antibiotic resistance, etc," he cautioned. But Dr. Harbarth noted that it is harder to prove to society and to hospital administrators that an antibiotic stewardship program is having an impact on these less tangible outcomes.
No commercial funding for the study was reported. Dr. Jump reports receiving consulting fees from GOJO and being a scientific advisor for Pfizer. Dr. Harbarth has disclosed no relevant financial relationships.
51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) : Abstract K-379. Presented September 17, 2011.
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