Effects of Antibiotic Cycling Policy on Incidence of Healthcare-Associated MRSA and Clostridioides difficile Infection in Secondary Healthcare Settings

Geraldine Mary Conlon-Bingham; Mamoon Aldeyab; Michael Scott; Mary Patricia Kearney; David Farren; Fiona Gilmore; James McElnay

Disclosures

Emerging Infectious Diseases. 2019;25(1):52-62. 

In This Article

Abstract and Introduction

Abstract

This quasi-experimental study investigated the effect of an antibiotic cycling policy based on time-series analysis of epidemiologic data, which identified antimicrobial drugs and time periods for restriction. Cyclical restrictions of amoxicillin/clavulanic acid, piperacillin/tazobactam, and clarithromycin were undertaken over a 2-year period in the intervention hospital. We used segmented regression analysis to compare the effect on the incidence of healthcare-associated Clostridioides difficile infection (HA-CDI), healthcare-associated methicillin-resistant Staphylococcus aureus(HA-MRSA), and new extended-spectrum β-lactamase (ESBL) isolates and on changes in resistance patterns of the HA-MRSA and ESBL organisms between the intervention and control hospitals. HA-CDI incidence did not change. HA-MRSA incidence increased significantly in the intervention hospital. The resistance of new ESBL isolates to amoxicillin/clavulanic acid and piperacillin/tazobactam decreased significantly in the intervention hospital; however, resistance to piperacillin/tazobactam increased after a return to the standard policy. The results question the value of antibiotic cycling to antibiotic stewardship.

Introduction

Restrictive antimicrobial prescribing guidelines have successfully reduced the incidence of Clostridioides difficile infection (CDI; formerly Clostridium difficile) and methicillin-resistant Staphylococcus aureus (MRSA).[1–6] However, these guidelines have been suggested to create an environment of antimicrobial homogeneity that may enhance the development and spread of antimicrobial resistance.[7,8] Antibiotic cycling has been proposed as an effective strategy to increase antimicrobial heterogeneity and decrease the development of antimicrobial resistance.[8,9] This method of increasing antimicrobial heterogeneity has had mixed effects on antimicrobial resistance; however, investigations have been conducted mainly in intensive care units (ICUs) and in patients with specific infections (neutropenic sepsis, ventilator-associated pneumonia), and cycling periods have been arbitrarily defined, ranging from 1 week to 6 months.[10–22] In a meta-analysis of studies investigating antibiotic cycling, the optimal cycling period was identified as 30 days.[23] When the cycling period is too long, the effect becomes equivalent to continuous use of a single agent, increasing antimicrobial homogeneity.

We aimed to evaluate the effect of an antibiotic cycling policy, derived using time-series analysis of retrospective epidemiologic data, on the incidence of healthcare-associated MRSA (HA-MRSA) and healthcare-associated CDI (HA-CDI). A secondary aim was to evaluate the effect of this policy on the incidence of infections caused by extended-spectrum β-lactamase (ESBL)–producing organisms.

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