1University Hospital of Besançon, Infection Control Department, F-25030 Besançon, France.
University Bourgogne-Franche-Comte, UMR 6249 Chrono-Environnement, F-25030 Besançon, France.
Antimicrob Resist Infect Control. 2018 Jan 22;7:11. doi: 10.1186/s13756-018-0302-8. eCollection 2018.
The ongoing extended spectrum β-lactamase-producing (ESBL-PE) pandemic has led to an increasing carbapenem use, requiring release of guidelines for carbapenem usage in France in late 2010. We sought to determine factors associated with changes in carbapenem use in intensive care units (ICUs), medical and surgical wards between 2009 and 2013.
This ward-level multicentre retrospective study was based on data from French antibiotic and multidrug-resistant bacteria surveillance networks in healthcare facilities. Antibiotic use was expressed in defined daily doses per 1000 patient-days. Factors associated with the reduction in carbapenem use (yes/no) over the study period were determined from random-effects logistic regression model (493 wards nested within 259 healthcare facilities): ward characteristics (type, size…), ward antibiotic use (initial antibiotic use [i.e., consumption of a given antibiotic in 2009], initial antibiotic prescribing profile [i.e., proportion of a given antibiotic in the overall antibiotic consumption in 2009] and reduction in the use of a given antibiotic between 2009 and 2013) and regional ESBL-PE incidence rate in acute care settings in 2011.
Over the study period, carbapenem consumption in ICUs ( = 85), medical ( = 227) and surgical wards ( = 181) was equal to 73.4, 6.2 and 5.4 defined daily doses per 1000 patient-days, respectively. Release of guidelines was followed by a significant decrease in carbapenem use within ICUs and medical wards, and a slowdown in use within surgical wards. The following factors were independently associated with a higher probability of reducing carbapenem use: location in Eastern France, higher initial carbapenem prescribing profile and reductions in consumption of fluoroquinolones, glycopeptides and piperacillin/tazobactam. In parallel, factors independently associated with a lower probability of reducing carbapenem use were ICUs, ward size increase, wards of cancer centres, higher initial third-generation cephalosporin (3GC) prescribing profile and location in high-risk regions for ESBL-PE.
Our study suggests that a decrease in 3GCs in the overall antibiotic use and the continuation of reduction in fluoroquinolone use, could allow reducing carbapenem use, given the well-demonstrated role of 3GCs and fluoroquinolones in the occurrence of ESBL-PE. Thus, antibiotic stewardship programs should target wards with higher 3GC prescription proportions to reduce them.
不断出现的产超广谱β-内酰胺酶（ESBL-PE）疫情导致碳青霉烯类药物的使用不断增加，因此法国在 2010 年底发布了碳青霉烯类药物使用指南。我们旨在确定 2009 年至 2013 年间，重症监护病房（ICU）和内科及外科病房中碳青霉烯类药物使用变化的相关因素。
本项基于法国医疗机构抗生素和多重耐药菌监测网络的数据，进行了病房水平的多中心回顾性研究。抗生素使用量以每 1000 个患者-天的限定日剂量表示。通过随机效应逻辑回归模型（嵌套在 259 家医疗机构中的 493 个病房），确定研究期间碳青霉烯类药物使用减少（是/否）的相关因素：病房特征（类型、规模等）、病房抗生素使用（初始抗生素使用[即在 2009 年使用特定抗生素]和初始抗生素处方特征[即在 2009 年抗生素总使用量中特定抗生素的比例]以及 2009 年至 2013 年间特定抗生素使用的减少）和 2011 年急性护理环境中区域 ESBL-PE 的发生率。
在研究期间，ICU（n=85）、内科（n=227）和外科病房（n=181）的碳青霉烯类药物消耗量分别等于每 1000 个患者-天 73.4、6.2 和 5.4 个限定日剂量。指南发布后，ICU 和内科病房的碳青霉烯类药物使用量显著减少，外科病房的使用量减少速度放缓。以下因素与更高的降低碳青霉烯类药物使用率的可能性相关：位于法国东部、初始碳青霉烯类药物处方特征较高以及氟喹诺酮类药物、糖肽类药物和哌拉西林/他唑巴坦使用率降低。同时，与降低碳青霉烯类药物使用率的可能性较低相关的因素包括 ICU、病房规模增加、癌症中心病房、初始第三代头孢菌素（3GC）处方特征较高以及产 ESBL-PE 高危地区。
我们的研究表明，鉴于 3GC 和氟喹诺酮类药物在 ESBL-PE 发生中的作用已得到充分证明，在抗生素总使用中减少 3GCs 和继续减少氟喹诺酮类药物的使用，可能会降低碳青霉烯类药物的使用。因此，抗生素管理计划应针对 3GC 处方比例较高的病房，以降低其比例。
