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Antibiotic Resistance in Long-Term Acute Care Hospitals The Perfect Storm

Published online by Cambridge University Press:  21 June 2016

Carolyn V. Gould ,
Richard Rothenberg  and
James P. Steinberg
Carolyn V. Gould*
Affiliation:
Department of Medicine, Division of Infectious Diseases, Rollins School of Public Health, Atlanta, Georgia
Richard Rothenberg
Affiliation:
Department of Medicine, Division of Infectious Diseases, Rollins School of Public Health, Atlanta, Georgia Emory University School of Medicine, and the Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia
James P. Steinberg
Affiliation:
Department of Medicine, Division of Infectious Diseases, Rollins School of Public Health, Atlanta, Georgia
*
550 Peachtree Street, Medical Office Tower, 7th Floor, Atlanta, GA30308, ([email protected])
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Abstract

Objective.

To examine bacterial antibiotic resistance and antibiotic use patterns in long-term acute care hospitals (LTACHs) and to evaluate effects of antibiotic use and other hospital-level variables on the prevalence of antibiotic resistance.

Design.

Multihospital ecologic study.

Methods.

Antibiograms, antibiotic purchasing data, and demographic variables from 2002 and 2003 were obtained from 45 LTACHs. Multivariable regression models were constructed, controlling for other hospital-level variables, to evaluate the effects of antibiotic use on resistance for selected pathogens. Results of active surveillance in 2003 at one LTACH were available.

Results.

Among LTACHs, median prevalences of resistance for several antimicrobial-organism pairs were greater than the 90th percentile value for National Nosocomial Infections Surveillance system (NNIS) medical intensive care units (ICUs). The median prevalence of methicillin resistance among Staphylococcus aureus isolates was 84%. More than 60% of patients in one LTACH were infected or colonized with methicillin-resistant S. aureus and/or vancomycin-resistant Enterococcus at the time of admission. Antibiotic consumption in LTACHs was comparable to consumption in NNIS medical ICUs. In multivariable logistic regression modeling, the only significant association between antibiotic use and the prevalence of antibiotic resistance was for carbapenems and imipenem resistance among Pseudomonas aeruginosa isolates (odds ratio, 11.88 [95% confidence interval, 1.42-99.13]; P = .02).

Conclusions.

The prevalence of antibiotic resistance among bacteria recovered from patients in LTACHs is extremely high. Although antibiotic use in LTACHs likely contributes to resistance prevalence for some antimicrobial-organism pairs, for the majority of such pairs, other variables, such as prior colonization with and horizontal transmission of antimicrobial-resistant pathogens, may be more important determinants. Further research on antibiotic resistance in LTACHs is needed, particularly with respect to determining optimal infection control practices in this environment.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 27 , Issue 9 , September 2006 , pp. 920 - 925
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2006

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References

1.Campbell, S. HCFA clamping down on long term acute care “hospitals within hospitals.” Health Care Strateg Manage 1997; 15:12–13.Google Scholar
2.Gould, CV, Steinberg, JP. Antibiotic resistance (AR) in long-term acute care hospitals (LTACHs): the perfect storm? Paper presented at: 14th Annual Meeting of the Society for Healthcare Epidemiology of America; April 18, 2004; Philadelphia, PA.Google Scholar
3.National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2003, issued August 2003. Am J Infect Control 2003; 31:481–498.Google Scholar
4.McGowan, JE. Antimicrobial resistance in hospital organisms and its relation to antibiotic use. Rev Infect Dis 1983; 5:1033–1048.CrossRefGoogle ScholarPubMed
5.Stratton, CW, Ratner, H, Johnston, PE, Schaffner, W. Focused microbiologic surveillance by specific hospital unit as a sensitive means of defining antimicrobial resistance problems. Diagn Microbiol Infect Dis 1992;15(2 Suppl):11S–18S.Google Scholar
6.Mutnick, AH, Rhomberg, PR, Sader, HS, Jones, RN. Antimicrobial usage and resistance trend relationships from the MYSTIC Programme in North America (1999-2001). J Antimicrob Chemother 2004; 53:290–296.CrossRefGoogle ScholarPubMed
7.Monnet, DL, Archibald, LK, Phillips, L, et al. Antimicrobial use and resistance in eight US hospitals: complexities of analysis and modeling. Infect Control Hosp Epidemiol 1998; 19:388–394.Google Scholar
8.Fridkin, SK, Steward, CD, Edwards, JR, et al. Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: Project ICARE Phase 2. Clin Infect Dis 1999; 29:245–252.Google Scholar
9.Fridkin, SK, Edwards, JR, Courval, JM, et al. The effect of vancomycin and third-generation cephalosporins on prevalence of vancomycin-resistant Enterococci in 126 U.S. adult intensive care units. Ann Intern Med 2001; 135:175–183.CrossRefGoogle ScholarPubMed
10.Ballow, CH, Schentag, JJ. Trends in antibiotic utilization and bacterial resistance: report of the National Nosocomial Resistance Surveillance Group. Diagn Microbiol Infect Dis 1992; 15:37S–42S.Google Scholar
11.Seppala, H, Klaukka, T, Vuopio-Varkila, J, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med 1997; 337:441–446.Google Scholar
12.Lepper, PM, Grusa, E, Reichl, H, Hogel, J, Trautmann, M. Consumption of imipenem correlates with β-lactam resistance in Pseudomonas aeruginosa. Antimicrob Agents Chemother 2002; 46:2920–2925.CrossRefGoogle ScholarPubMed
13.Zervos, MJ, Hershberger, E, Nicolau, DP, et al. Relationship between fluoroquinolone use and changes in susceptibility to fluoroquinolones of selected pathogens in 10 United States teaching hospitals, 1991-2000. Clin Infect Dis 2003; 37:1643–1648.CrossRefGoogle ScholarPubMed
14.Rahal, JJ, Urban, C, Horn, D, et al. Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella. JAMA 1998; 280:1233–1237.CrossRefGoogle ScholarPubMed
15.Rice, LB, Eckstein, EC, DeVente, J, Schlaes, DM. Ceftazidime-resistant Klebsiella pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical Center. Clin Infect Dis 1996; 23:118–124.Google Scholar
16.Archibald, LK, Phillips, L, Monnet, DL, McGowan, JE, Tenover, FC, Gaynes, RP. Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit. Clin Infect Dis 1997; 24:211–215.Google Scholar
17.Livingstone, D, Gill, MJ, Wise, R. Mechanisms of resistance to the carbapenems. J Antimicrob Chemother 1995; 35:1–5.CrossRefGoogle Scholar
18.Lautenbach, E, Bilker, WB, Brennan, PJ. Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality. Infect Control Hosp Epidemiol 1999; 20:318–323.Google Scholar
19.Shay, DK, Maloney, SA, Montecalvo, M, et al. Epidemiology and mortality risk of vancomycin-resistant enterococcal bloodstream infections. J Infect Dis 1995; 172:993–1000.Google Scholar
20.Harbarth, S, Harris, AD, Carmeli, Y, Samore, MH. Parallel analysis of individual and aggregated data on antibiotic exposure and resistance in gram-negative bacilli. Clin Infect Dis 2001; 33:1462–1468.CrossRefGoogle ScholarPubMed
21.Greenland, S. Divergent biases in ecologic and individual-level studies. Stat Med 1992; 11:1209–1223.CrossRefGoogle ScholarPubMed
22.Ho, PL, For the Hong Kong intensive care unit antimicrobial resistance study (HK-ICARE) Group. Carriage of methicillin-resistant Staphylococcus aureus, ceftazidime-resistant gram-negative bacilli, and vancomycin-resistant enterococci before and after intensive care unit admission. Crit Care Med 2003; 31:1175–1182.Google Scholar
23.Lipsitch, M, Bergstrom, CT, Levin, BR. The epidemiology of antibiotic resistance in hospitals: paradoxes and prescriptions. Proc Natl Acad Sci USA 2000; 97:1938–1943.CrossRefGoogle ScholarPubMed
24.Muto, CA, Jernigan, JA, Ostrowsky, BE, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol 2003; 24:362–386.Google Scholar
25.Shlaes, DM, Gerding, DN, John, JF, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America joint committee on the prevention of antimicrobial resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997; 18:275–291.Google Scholar
26.Garner, JS. Guideline for isolation precautions in hospitals. Part I. Evolution of isolation practices. Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996; 24:24–31.Google Scholar
27.Austin, DJ, Bonten, MJM, Weinstein, RA, Slaughter, S, Anderson, RM. Vancomycin-resistant enterococci in intensive-care unit hospital settings: transmission dynamics, persistence, and the impact of infection control measures. Proc Natl Acad Sci USA 1999; 96:6908–6913.CrossRefGoogle Scholar