BACKGROUND. Intensive care units (ICUs) are "hot" areas for antibiotic consumption, infection and antibiotic resistance. Resistance affects patient outcomes, resource utilization and determines whether treatments are adequate. Within Europe, Italy has among the highest rates of antibiotic consumption but resistances - particularly in ICUs - are largely unexplored, both nationally and regionally. OBJECTIVES. To assess variation in antibiotic prescribing, consumption, resistance, and treatment outcomes and to identify critical points for improvement in antimicrobial practice across 5 ICUs in the Veneto region, North-east Italy. RESULTS. From 2002 to 2010, 911 patients were reviewed. Median K'U stay (17 days; IQR, 8-29) and ICU mortality (mean, 24.9%) were similar across sites. Empirical antibiotics were given to 853 patients (83.1%), with penicillin/β-lactamase inhibitor combinations (26%), cephalosporins (20.7%), fluoroquinolones (10.9%), and carbapenems (9.8%) frequently used. Laboratory investigation was often long delayed (median 7 days IQR = 3-14) after treatment initiation, and there were few (37.2%) microbiological-based shifts; 30.9% of empirical regimens were inadequate. Treatment inadequacy (AOR=13.99) and septic shock (AOR=3.29) were the main independent predictors for hospital mortality. Amongst 1908 isolates tested - predominantly, Pseudomonas aeruginosa (22%) and MRSA (14.8%) - 53.7% were multiresistant, with significant inter-hospital differences in resistance rates of Enterobacteriaceae to fluoroquinolones, and for P. aeruginosa to fluoroquinolones and carbapenems) (p < 0.001). The relationship between resistance and use of fluoroquinolones and 3rd_ generation cephalosporins was clear for Enterobacteriaceae (p < 0.001), but weaker for P. aeruginosa. The susceptibility of Escherichia coli to fluoroquinolones decreased over time (X2 = 0.009). Antibiotic use was inflated, especially at one ICU with excess of fluoroquinolone (94.4 DDD/100 bed-days vs. 26.1-35.9 elsewhere) use. CONCLUSIONS. Considerable inter-hospital variation III prescribing affected antibiotic consumption and resistance prevalence. Poor and delayed use of laboratory microbiology was prominent, as was the uncontrolled use of antibiotics. Urgent interventions are needed and improvement strategies are discussed.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:568962 |
| Date | January 2011 |
| Creators | Benedetti, Paolo |
| Publisher | Queen Mary, University of London |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
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