A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance

BACKGROUND: Examination of knowledge, attitudes, and beliefs of house staff physicians will be important in developing interventions to improve antimicrobial use and prevent resistance. METHODS: A 75-item survey was distributed to house staff physicians on nonpediatric services in a university teaching hospital. Knowledge was assessed with a 10-question quiz. RESULTS: The survey was completed by 179 (67%) of 269 house staff physicians on 5 specialties. Outside and inside the intensive care unit, 21% and 25% of respondents, respectively, reported that they were using antibiotics optimally. Surgeons were significantly more likely than other physicians to report that they were regularly seeking input into antimicrobial selections (P<.001). Of the 170 physicians who completed the survey, 88% agreed antibiotics are overused in general and 72% also agreed this was the case at their institution (r = 0.56; P<.05); 96% agreed that hospitals in general face serious problems with antibiotic resistance and 93% agreed that their hospital faces these same problems (r = 0.57; P<.05); 97% agreed that better use of antibiotics would reduce resistance; 32% stated that they had not had formal teaching on antimicrobial agents in the last year (medicine residents reported significantly more formal teaching than others [P =.001]); and 90% wanted more education about antimicrobials and 67% wanted more feedback on antimicrobial selections. The mean antimicrobial quiz score was 28%, with medicine residents scoring significantly higher than others (P =.04). Upper-level residents did not perform better than interns. CONCLUSIONS: This survey (1) revealed that house staff are aware of the importance of antimicrobial resistance and believe better antimicrobial use will help this problem and (2) demonstrated differences between specialties with respect to antimicrobial use and knowledge. House staff at our hospital have suboptimal knowledge about antimicrobials, and this knowledge did not increase appreciably over the course of their training. Antimicrobial education is needed and is likely to be well received by house staff physicians in academic centers but may be more effective if it is tailored to specific specialties.     

Antibiotic resistance in the intensive care unit

Antimicrobial resistance has emerged as an important determinant of outcome for patients in the intensive care unit (ICU). This is largely due to the administration of inadequate antimicrobial treatment, which is most often related to bacterial antibiotic resistance. In addition, the escalating problem of antimicrobial resistance has substantially increased overall health care costs. This increase is a result of prolonged hospitalizations and convalescence associated with antibiotic treatment failures, the need to develop new antimicrobial agents, and the implementation of broader infection control and public health interventions aimed at curbing the spread of antibiotic-resistant pathogens. Intensive care units are unique because they house seriously ill patients in confined environments where antibiotic use is extremely common. They have been focal points for the emergence and spread of antibiotic-resistant pathogens. Effective strategies for the prevention of antimicrobial resistance in ICUs have focused on limiting the unnecessary use of antibiotics and increasing compliance with infection control practices. Clinicians caring for critically ill patients should consider antimicrobial resistance as part of their routine treatment plans. Careful, focused attention to this problem at the local ICU level, using a multidisciplinary approach, will have the greatest likelihood of limiting the development and dissemination of antibiotic-resistant infections.     

Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: project ICARE phase 2. Project Intensive Care Antimicrobial Resistance Epidemiology (ICARE) hospitals.

The search for the means to understand and control the emergence and spread of antimicrobial resistance has become a public health priority. Project ICARE (Intensive Care Antimicrobial Resistance Epidemiology) has established laboratory-based surveillance for antimicrobial resistance and antimicrobial use at a subset of hospitals participating in the National Nosocomial Infection Surveillance system. These data illustrate that for most antimicrobial-resistant organisms studied, rates of resistance were highest in the intensive care unit (ICU) areas and lowest in the outpatient areas. A notable exception was ciprofloxacin- or ofloxacin-resistant Pseudomonas aeruginosa, for which resistance rates were highest in the outpatient areas. For most of the antimicrobial agents associated with this resistance, the rate of use was highest in the ICU areas, in parallel to the pattern seen for resistance. These comparative data on use and resistance among similar areas (i.e., ICU or other inpatient areas) can be used as a benchmark by participating hospitals to focus their efforts at addressing antimicrobial resistance.     

Antibiotic resistance: a survey of physician perceptions

BACKGROUND: Antibiotic resistance is caused partly by excessive antibiotic prescribing, yet little is known about prescribers' views on this problem. METHODS: We surveyed 490 internal medicine physicians at 4 Chicago-area hospitals to assess their attitudes about the importance of antibiotic resistance, knowledge of its prevalence, self-reported experience with antibiotic resistance, beliefs about its causes, and attitudes about interventions designed to address the problem. RESULTS: The response rate was 87% (424 of 490 physicians). Antibiotic resistance was perceived as a very important national problem by 87% of the respondents, but only 55% rated the problem as very important at their own hospitals. Nearly all physicians (97%) believed that widespread and inappropriate antibiotic use were important causes of resistance. Yet, only 60% favored restricting use of broad-spectrum antibiotics, although this percentage varied by hospital and physician group. CONCLUSIONS: Although most physicians view antibiotic resistance as a serious national problem, perceptions about its local importance, its causes, and possible solutions vary more widely. Disparities in physician knowledge, beliefs, and attitudes may compromise efforts to improve antibiotic prescribing and infection control practices.     

Antibiotic susceptibility of staphylococci isolated in blood cultures in relation to antibiotic consumption in hospital wards.

A total of 510 isolates of Micrococcaceae, 500 of staphylococci and 10 micrococci, detected in 485 (3.3%) of 14,860 consecutive blood cultures obtained from patients at a Swedish university hospital and 2 local hospitals were identified to species level and investigated for antibiotic susceptibility. The 5 most frequently isolated species were Staphylococcus epidermidis (54.8%), S. aureus (28.0%), S. hominis (3.4%), S. warneri (3.2%) and S. haemolyticus (2.8%). All isolates of S. aureus were oxacillin sensitive. Great diversity in antibiotic resistance among coagulase negative staphylococci between hospitals and different ward units in the university hospital was observed. The frequency of antimicrobial resistance among S. epidermidis correlated with the antibiotic consumption at different ward units, in particular for ciprofloxacin (p < 0.001) and co-trimoxazole (p < 0.004). The study emphasizes the importance of monitoring antibiotic consumption and resistance patterns of nosocomial staphylococci in order to avoid emergence and spread of multi-resistant bacteria within the hospital environment.     

Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC,SEFH y SEMPSPH

The antimicrobial agents are unique drugs for several reasons. First, their efficacy is higher than other drugs in terms of reduction of morbidity and mortality. Also, antibiotics are the only group of drugs associated with ecological effects, because their administration may contribute to the emergence and spread of microbial resistance. Finally, they are used by almost all medical specialties. Appropriate use of antimicrobials is very complex because of the important advances in the management of infectious diseases and the spread of antibiotic resistance. Thus, the implementation of programs for optimizing the use of antibiotics in hospitals (called PROA in this document) is necessary.     

The enterococcus: "putting the bug in our ears"

High-level resistance to gentamicin among clinical isolates of enterococci has been found with increasing frequency in recent years. In this issue, Zervos and colleagues report findings from a prospective study in which they assessed the frequency of colonization and infection with such organisms at a university medical center, demonstrating probable person-to-person spread. Their findings suggest that hospitals should conduct systematic screening for enterococci with high-level resistance to gentamicin, that antimicrobial treatment habits be modified to limit the emergence of such organisms, and that rigorous infection control be practiced to minimize their spread. These observations are particularly timely because it has become clear that enterococci are extremely versatile pathogens which are both well suited for survival and capable of causing serious illness, especially in hospitalized patients treated with some of the newer broad-spectrum antibiotic agents. Enterococci with high-level resistance to gentamicin are also of growing concern because their resistance to many antibiotic agents severely limits the clinician's options for treatment.     

Evolution of antimicrobial resistance: impact on antibiotic use

During the past 50 years, the permanent increase in bacterial resistance to antibiotics has led to modifications in therapeutic recommendations. Despite evidence that antimicrobial exposure of human populations is the most important driving force for the continuous increase in bacterial resistance, the studies of the impact of bacterial resistance on antibiotic use have, during the past, focused on clinical efficacy of individual treatments rather than on collective control of resistance. There are current changes in this attitude, mainly in hospitals, probably because hospital prescribers have experienced the consequences of resistance on their patients. However, in the community such an awareness is not likely to develop in the near future. Therefore, there is a need for public health decision makers to become more involved in prevention of the impact of resistance in antibiotic use.     

Ecological theory suggests that antimicrobial cycling will not reduce antimicrobial resistance in hospitals

Hospital-acquired infections caused by antibiotic-resistant bacteria pose a grave and growing threat to public health. Antimicrobial cycling, in which two or more antibiotic classes are alternated on a time scale of months to years, seems to be a leading candidate in the search for treatment strategies that can slow the evolution and spread of antibiotic resistance in hospitals. We develop a mathematical model of antimicrobial cycling in a hospital setting and use this model to explore the efficacy of cycling programs. We find that cycling is unlikely to reduce either the evolution or the spread of antibiotic resistance. Alternative drug-use strategies such as mixing, in which each treated patient receives one of several drug classes used simultaneously in the hospital, are predicted to be more effective. A simple ecological explanation underlies these results. Heterogeneous antibiotic use slows the spread of resistance. However, at the scale relevant to bacterial populations, mixing imposes greater heterogeneity than does cycling. As a consequence, cycling is unlikely to be effective and may even hinder resistance control. These results may explain the limited success reported thus far from clinical trials of antimicrobial cycling.     

The role of the microbiologist in the control of nosocomial infection and antibiotic therapy

The microbiologist is a key figure in the control of hospital infection and in antimicrobial policy. Some of the contributions to the area of documentation and information can be summarized as follows: information on the development of isolation of sentinel microorganisms and their distribution in services and areas, the development of resistance of the various microorganisms to the most commonly used antimicrobial agents, molecular characterization of the isolated microorganisms causing epidemic outbreaks and the control of environmental microorganisms posing a threat to hospitals.Concerning interventions, microbiologists make a substantial contribution to teaching activity and to the continuing education required to maintain optimal knowledge on infections and microbiology in hospitals. They also recommend therapeutic approaches to the presence of isolated microorganisms and specific situations, collaborate in the design of antimicrobial prophylaxis and illustrate the policy of patient isolation. Microbiologists play a key role in decisions to introduce new drugs in hospitals and in programs to limit their inappropriate use.Finally, microbiologists and microbiology services constitute a central element where all the activities required for the diagnosis, treatment and control of infection performed by the various hospital services converge.     

Regulation of antimicrobial prescribing practices—a strategy for controlling nosocomial antimicrobial resistance

Approximately 10% of hospital in-patients in the UK acquire nosocomial infection, with an increasing number of these infections caused by multiresistant organisms. It is essential to halt the development and spread of antibiotic resistance among hospital pathogens.The relationship between antibiotic use and the development of antibiotic resistance in microorganisms is a subject of ongoing controversy and research. However, there is a general acceptance that control of antibiotic prescribing within hospitals is fundamental to controlling the development of nosocomial antibiotic resistance. In order to achieve this, there is a need to design and successfully implement targeted antibiotic policies based on local patterns of resistance. Traditional educational methods used alone for executing such policies have not been shown to be effective. Computer-based technology shows great promise but will require considerable resource allocation for its installation.Of equal importance, the Infection Control Team must be given a high profile. Robust surveillance systems to gather epidemiological data on local prescribing practices, hospital infection control policy compliance, antibiotic resistance and hospital infection rates need to be set up within individual hospitals. The appointment of an anti-infective pharmacist should be considered. Delivery of an integrated antibiotic and infection control service requires a coordinated, multidisciplinary team approach with clear leadership. Finally, in order for any strategy to be successful, the full support of hospital management is essential.     

Bacterial resistance and topical antimicrobial wash products.

Current scientific evidence has not shown that a link exists between the use of topical antimicrobial formulations and antiseptic or antibiotic resistance. As a result of the extensive history and varied use of antiseptic products and ingredients, any selective pressure for antibiotic resistance that may be occurring or may be uncovered in the future because of antiseptic use would be expected to be insignificant compared with the selective pressure because of antibiotic use. This review illustrates the effectiveness of topical antimicrobial wash products against antibiotic-resistant and antiseptic-resistant bacteria in use settings as well as the studies performed (antiseptic, deodorant, and oral care) demonstrating the lack of development of resistance in long-term clinical studies. Although these studies illustrate that the use of topical antimicrobial products have not been shown to play a role in the fluctuations of the specific composition or resistance of the skin flora, changes in skin flora have been shown to occur. Based on current knowledge, the benefit from use of topical antimicrobial wash products in combination with standard infection control and personal hygiene practices far outweighs the risk of increased antibiotic resistance.     

Antimicrobial resistance in hospital organisms and its relation to antibiotic use

Organisms causing nosocomial infection are frequently resistant to antimicrobial agents. Studies of the reasons for this have been hindered by difficulties in defining terms, by selection biases, by artifacts produced by study methods, and by failure to control for confounding variables. Major factors leading to increased prevalence of resistant organisms in hospitals are changes in organisms causing nosocomial infection (due in part to changes in characteristics of hospital populations and in procedures and instruments used in patient care), increasing prevalence of resistance in bacteria causing community-acquired infection, and use of antimicrobial agents. A causal relationship between antibiotic usage and resistance of hospital organisms is supported by consistent association and concurrent variation in several populations, presence of a dose-response pattern, and existence of a reasonable biologic model to explain the relationship. Major influences on emergence of resistant hospital bacteria include antimicrobial effects in treated individuals, mechanisms for transfer of resistance between bacteria, and routes of transmission within the hospital for bacteria or their resistance factors. Barrier isolation techniques can help control resistant hospital bacteria. However, virtually all reports agree that careful, discriminating use of antimicrobial agents remains the keystone for minimizing this problem. This need must be communicated more effectively to prescribers.     

Current practice of peri- and postoperative antibiotic therapy in cardiac surgery in Germany. Working Group on Cardiothoracic Surgical Intensive Care Medicine of the German Society for Thoracic and Cardiovascular Surgery

BACKGROUND: The increasing development of antimicrobial resistance of common bacterial pathogens presents one of the most significant challenges to clinical medicine, particularly intensive care medicine. One factor which has contributed to this development is the (over)use of antibiotic treatment. Therefore the objective of this study was to scrutinize the current practice of empiric antibiotic therapy in cardiac surgery in Germany for 1) perioperative prophylaxis and 2) postoperative therapy prior to the availability of susceptibility patterns for the infecting pathogen. METHODS: A questionnaire was sent to all centers performing cardiac surgery in Germany. Questions referred to drugs used as well as dosage, homogeneity and duration of antibiotic prophylaxis, time and/or reason for changing this regimen, drugs used for first-, second-, and third-line empiric postoperative antibiotic treatment, and homogeneity of antibiotic usage. RESULTS: All but 3 institutions (96.3%) answered. 1. Perioperative prophylaxis: All but 4 centers (94%) use first- (n = 32 = 43%) or second-generation cephalosporins (n = 38 = 51%) most commonly for 24 hours (n = 60 = 81%). Prophylaxis never exceeds 3 days. 74% of all institutions (n = 55) use the same antimicrobial agent for all cardiac procedures performed, while 26% (n = 19) change their regimen in selected patient groups, most commonly for heart transplantation. The entire prophylaxis is changed mainly according to susceptibility patterns (n = 63 = 85%), 7 centers (10%) change according to a fixed time schedule, while 4 institutions (5%) never change the antimicrobial drug. 2. Empiric postoperative therapy: A total of 29 different antibiotics out of 8 subclasses are used. No major differences between 1st-, 2nd-, and 3rd-line therapy could be detected, with the exception of a decreasing usage of beta-lactams (carbapenems excluded) from 60% in 1st-line to 23% in 3rd-line therapy and an increasing usage of glycopeptides from 5% in 1st-line to 18% in 3rd-line therapy. 41 institutions (55%) use the same antibiotic regimen on the intensive care unit and the normal ward, 9 centers (12%) use the same drug for perioperative prophylaxis and postoperative therapy, and 12 institutions (16%) prescribe a combination therapy. CONCLUSIONS: Perioperative prophylaxis in cardiac surgery in Germany is performed on a relatively uniform basis and at low cost. The heterogeneity of antibiotic regimens for postoperative therapy may indicate the need for recommendations and/or guidelines for this type of treatment. The indications for the usage of reserve antibiotics, e.g. vancomycin, implying the possible risk of creating pathogens with untreatable resistance patterns, as well as strategies aimed at preventing the development of resistance should be the subject of further discussions.     

Measurement of antibiotic consumption: A practical guide to the use of the Anatomical Thgerapeutic Chemical classification and Definied Daily Dose system methodology in Canada.

Despite the global public health importance of resistance of microorganisms to the effects of antibiotics, and the direct relationship of consumption to resistance, little information is available concerning levels of consumption in Canadian hospitals and out-patient settings. The present paper provides practical advice on the use of administrative pharmacy data to address this need. Focus is made on the use of the Anatomical Therapeutic Chemical classification and Defined Daily Dose system. Examples of consumption data from Canadian community and hospital settings, with comparisons to international data, are used to incite interest and to propose uses of this information. It is hoped that all persons responsible for policy decisions regarding licensing, reimbursement, prescribing guidelines, formulary controls or any other structure pertaining to antimicrobial use become conversant with the concepts of population antibiotic consumption and that this paper provides them with the impetus and direction to begin accurately measuring and comparing antibiotic use in their jurisdictions.