Cutting ciprofloxacin reduces Pseudomonas
'What we were dealing with was habits'
A North Carolina hospital's program to restrict ciprofloxacin use in intensive care units was associated with a significant decreasing trend of Pseudomonas aeruginosa resistant isolates.
The hospital has collected data and monitored antibiotic use since 1999, says Paul P. Cook, MD, director of antibiotic management program at Vidant Medical Center in Greenville, NC. Cook also is a professor of medicine and chief of the division of infectious diseases at Brody School of Medicine, East Carolina University in Greenville.
"We saw that we were using a lot of ciprofloxacin in our hospital, and we observed in our microbiology lab a lot of resistance, particularly in Pseudomonas," Cook explains.
The hospital's pharmacists tried to convince physicians to stop prescribing ciprofloxacin. But the voluntary efforts at stewardship did not go far enough.
"Then we switched to an electronic medical record in 2007, so we decided to restrict ciprofloxacin, requiring approval for prescriptions from an infectious disease physician," Cook says.
The hospital's antibiotic management program is a subcommittee of the therapeutics committee, and both groups approved the change to restricted use of ciprofloxacin.
The program has pharmacists make a recommendation regarding antibiotic use, and the provider does not have to respond for the recommended drug to be prescribed. If a physician disagrees, then the case is reviewed and infectious disease physicians provide input.
The restriction worked. At first some physicians disagreed with the recommendations, although about 85% of the recommendations were accepted, Cook says.
When physicians agreed or said nothing, the recommendation became an order with Cook's signature on it.
"After we started using electronic medical records in 2007, we were able to review more charts and we made more recommendations for antibiotic use, and our acceptance rate went up to 92%," Cook says.
"Our use of ciprofloxacin went from being very high to not so high at first, but once we restricted it, the use actually went low," he says. "We monitored this over a 10-year-period in the ICU."
Data showed that the use of other antibiotics, such as carbapenems, increased, as expected.
Also, susceptibility to ciprofloxacin improved, but there was another surprising and positive outcome: susceptibility to carbapenems also improved.
"We hypothesized that ciprofloxacin increases the efflux pumps that are responsible for resistance to a variety of drugs, including carbapenems," Cook explains. "So if we use more ciprofloxacins we get resistance to both ciprofloxacins and carbapenems, and if we use less we get less resistance to both."
The key to the program's success was making antibiotic stewardship of ciprofloxacin a quality issue, combined with increased prescriber education.1 The hospital also obtained physician buy-in before requiring approval for ciprofloxacin prescriptions.
"What we were dealing with was habits," Cook says. "In 2000, ciprofloxacin was the most commonly used drug in the hospital. We had to get people to stop using an antibiotic they were extremely comfortable using."
Cook recalls a conversation with a urologist who said, "We've used this drug for 15 years and it's our go-to drug." Cook responded: "Yes, this drug 15 years ago was so good that it would work, but now it's overused and won't work."
He showed physicians the susceptibility data and patterns for pseudomonas and other common nosocomial infections like E. coli. Fifteen to 20 years ago, the drug was 95% to 98% susceptible to those infections, compared with a current susceptibility for ciprofloxacin of 70%, Cook says.
"That's a big difference if you're talking about patient care," he notes. "Providers are much more comfortable using a drug that has a 98% chance of being effective, so this can have significant consequences for patient care."
The next step was to find an alternative drug for doctors to prescribe.
"We picked some indications where we saw ciprofloxacin being used and looked at what we could offer that would be just as effective," Cook says. "We picked ertapenem, a carbapenem."
Although the program has been in place for years, it continues to evolve and physician education and buy-in continues.
"Over many years we did grand rounds, presentations, and individual conversations with physicians and providers about specific issues and specific patients," Cook says. "But what we clearly have told the physicians is that we are not demanding that our recommendations be accepted, we are strongly recommending it, but the physician has the right to opt-out."
The program's success is its biggest marketing tool: "We've shown that MRSA infection rates have decreased since our program started, and we also showed a slight decrease in Clostridium difficile since 2007," Cook says.
"It's not a debatable issue that we as a society are using too many antibiotics," Cook says. "These programs reduce the unnecessary use — not to zero — but they help, and this is critical to ensure better patient care."
Reference
- Lewis GJ, Fang X, Gooch M, et al. Decreased resistance of pseudomonas aeruginosa with restriction of ciprofloxacin in a large teaching hospital's intensive care and intermediate care units. Infect Contrl Hosp Epidemiol 2012;33(4):368-373.
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