liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Surveillance of Antibiotic Consumption and Antibiotic Resistance in Swedish Intensive Care Units
Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Nosocomial infections remain a major cause of mortality and morbidity. The problem is most apparent in intensive care units (ICUs). Most ICU patients are compromised and vulnerable as a result of disease or severe trauma. One in ten people admitted to hospital is given an antibiotic for infection. The risk of acquiring a nosocomial infection in a European ICU is approximately 20%. It is vitally important that ways are found to prevent transmission between patients and personnel, and that local hygiene routines and antibiotic policies are developed. This thesis is a holistic work focused particularly on antimicrobial antibiotic resistance, antibiotic consumption and to some extent on hygiene in Swedish ICUs.

Aims: The general aim of this thesis was to investigate bacterial resistance and antibiotic consumption in Swedish ICUs and to try to correlate ICU demographic data with antibiotic consumption and antibiotic resistance. Additional aims were to investigate on which clinical indications antibacterial drugs are prescribed in the ICU, and to investigate the emergence of resistance and transmission of Pseudomonas aeruginosa in the ICU using cluster analysis based on antibiograms and genotype data obtained by AFLP.

Material and methods: In paper 1-3, antibiotic consumption data together with bacterial antibiotic resistance data and specific ICU-demographic data were collected from an increasing number of ICUs over the years 1997-2001. Data from ICUs covering up to six million out of Sweden’s nine million inhabitants were included. In paper 4, the indications for antibiotic prescribing were studied during two weeks in 2000. Paper 5 investigated Pseudomonas aeruginosa isolates in order to detect cross-transmission with genotype obtained by AFLP, and antibiogram-based cluster analysis was also performed in order to see if this could be a quicker and easier substitute for AFLP.

Results: This thesis has produced three important findings. Firstly, antibiotic consumption in participating ICUs was relatively high during the study period, and every patient received on average more than one antimicrobial drug per day (I-IV). Secondly, levels of antimicrobial drug resistance seen in S. aureus, E. coli and Klebsiella spp remained low when data were pooled from all ICUs throughout the study period, despite relatively high antibiotic consumption (I-V). Thirdly, the prevalence of antibiotic resistance in CoNS and E. faecium, cefotaxime resistance in Enterobacter, and ciprofloxacin and imipenem resistance in P. aeruginosa was high enough to cause concern.

Conclusion: For the period studied, multidrug resistance in Swedish ICUs was not a major problem. Signs of cross-transmission with non-multiresistant bacteria were observed, indicating a hygiene problem and identifying simple improvements that could be made in patient care guidelines and barrier precautions. A need for better follow up of prescribed antibiotics was evident. With further surveillance studies and monitoring of antibiotics and bacterial resistance patterns in the local setting as well as on a national and international level, some of the strategic goals in the prevention and control of the emergence of antimicrobial-resistant microbes may be achievable.

Place, publisher, year, edition, pages
Institutionen för molekylär och klinisk medicin , 2007.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1019
Keyword [en]
Bacterial Antibiotic resistance, Antibiotic Consumption, ICU, Surveillance programme, Multi drug resistance, Pseudomonas aeruginosa, ICU demography
National Category
Infectious Medicine
Identifiers
URN: urn:nbn:se:liu:diva-10049ISBN: 978-91-85895-77-9 (print)OAI: oai:DiVA.org:liu-10049DiVA: diva2:16802
Public defence
2007-10-26, Elsa Brändströmsalen, University Hospital, Linköping University, 581 85 Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2007-10-18 Created: 2007-10-18 Last updated: 2009-08-22
List of papers
1. Surveillance of Antibiotic Resistance in ICUs in Southeastern Sweden
Open this publication in new window or tab >>Surveillance of Antibiotic Resistance in ICUs in Southeastern Sweden
Show others...
1999 (English)In: Acta Anaesthesiol Scand, Vol. 43, no 8, 815-820 p.Article in journal (Refereed) Published
Abstract [en]

Background: A study was designed to assess a computer-based program for continuous registration of antibiotic resistance, statistics concerning severity of illness, and consumption of antibacterial drugs.

Methods: The frequency of antibiotic resistance among bacteria in eight ICUs in southeastern Sweden was investigated yearly from 1995 through 1997. The antibiotic consumption in the ICUs was registered as defined daily doses (DDD) and compared to severity of illness (APACHE-II scores).

Results: There was a statistically significant increase in ampicillin resistance among Enterococcus spp. between 1996 and 1997, which was due to a shift from Enterococcus faecalis to Enterococcus faecium. A high prevalence of resistance among coagulase-negative staphylococci to oxacillin (≈ 70%), ciprofloxacin (≈ 50%), fucidic acid (≈ 50%) and netilmicin (≈ 30%) was seen in all ICUs during the whole study period. There was a statistically significant increase in ciprofloxacin resistance among Escherichia coli and Enterococcus spp. The resistance among Enterobacter spp. to cefotaxime decreased but this change was not statistically significant. Efforts were made to avoid betalactam antibiotics, except carbapenems, for treatment of infections caused by Enterobacter spp. and the consumption of cephalosporins decreased whereas the consumption of carbapenems increased. The total antibiotic consumption decreased by 2.5% during the study period. There was no correlation between APACHE II scores and antibiotic consumption.

Conclusions: Each ICU within a hospital ought to have a program for "on-line" antibiotic resistance surveillance of drugs used in that unit so that changes in empirical treatment can be made when there is an increase in antibiotic-resistant isolates within that unit.

Keyword
Antibiotic resistance, intensive care units, antibiotic consumption, ICU-infections
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12662 (URN)10.1034/j.1399-6576.1999.430806.x (DOI)
Available from: 2007-10-18 Created: 2007-10-18 Last updated: 2009-08-18
2. Antibiotic prescription practices, consumption and bacterial resistance in a cross section of Swedish intensive care units
Open this publication in new window or tab >>Antibiotic prescription practices, consumption and bacterial resistance in a cross section of Swedish intensive care units
Show others...
2002 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, Vol. 46, no 9, 1075-1081 p.Article in journal (Refereed) Published
Abstract [en]

Background: The purpose of this work was to study usage of antibiotics, its possible determinants, and patterns of bacterial resistance in Swedish intensive care units (ICUs).

Methods: Prospectively collected data on species and antibiotic resistance of clinical isolates and antibiotic consumption specific to each ICU in 1999 were analyzed together with answers to a questionnaire. Antibiotic usage was measured as defined daily doses per 1000 occupied bed days (DDD1000).

Results: Data were obtained for 38 ICUs providing services to a population of approximately 6 million. The median antibiotic consumption was 1257 DDD1000 (range 584–2415) and correlated with the length of stay but not with the illness severity score or the ICU category. Antibiotic consumption was higher in the ICUs lacking bedside devices for hand disinfection (2193 vs. 1214 DDD1000, p=0.05). In the ICUs with a specialist in infectious diseases responsible for antibiotic treatment the consumption pattern was different only for use of glycopeptides (58% lower usage than in other ICUs: 26 vs. 11 DDD1000,P=0.02). Only 21% of the ICUs had a written guideline on the use of antibiotics, 57% received information on antibiotic usage at least every 3 months and 22% received aggregated resistance data annually. Clinically significant antimicrobial resistance was found among Enterbacter spp. to cephalosporins and among Enterococcus spp. to ampicillin.

Conclusions: Availability of hand disinfection equipment at each bed and a specialist in infectious diseases responsible for antibiotic treatment were factors that correlated with lower antibiotic consumption in Swedish ICUs, whereas patient-related factors were not associated with antibiotic usage.

Keyword
Anti-infective agents, critical care, cross infection, multiple drug resistance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12663 (URN)10.1034/j.1399-6576.2002.460904.x (DOI)
Available from: 2007-10-18 Created: 2007-10-18 Last updated: 2009-08-21
3. High Antibiotic Susceptibility Among Bacterial Pathogens In Swedish ICUs
Open this publication in new window or tab >>High Antibiotic Susceptibility Among Bacterial Pathogens In Swedish ICUs
Show others...
2004 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 36, no 1, 24-30 p.Article in journal (Refereed) Published
Abstract [en]

Local infection control measures, antibiotic consumption and patient demographics from 1999-2000 together with bacteriological analyses were investigated in 29 ICUs participating in the ICU-STRAMA programme. The median antibiotic consumption per ICU was 1147 (range 605-2143) daily doses per 1000 occupied bed d (DDD1000). Antibiotics to which >90% of isolates of an organism were susceptible were defined as treatment alternatives (TA90). The mean number of TA90 was low (1-2 per organism) for Enterococcus faecium (vancomycin:VAN), coagulase negative staphylococci (VAN), Pseudomonas aeruginosa (ceftazidime:CTZ, netilmicin: NET) and Stenotrophomonas maltophilia (CTZ, trimethoprim-sulfamethoxazole: TSU), but higher (3-7) for Acinetobacter spp. (imipenem:IMI, NET, TSU), Enterococcus faecalis (ampicillin:AMP, IMI, VAN), Serratia spp. (ciprofloxacin:CIP, IMI, NET), Enterobacter spp. (CIP, IMI, NET, TSU), E. coli (cefuroxime:CXM, cefotaxime/ceftazidime:CTX/CTZ, CIP, IMI, NET, piperacillin-tazobactam:PTZ, TSU), Klebsiella spp. (CTX/CTZ CIP, IMI, NET, PTZ, TSU) and Staphylococcus aureus (clindamycin, fusidic acid, NET, oxacillin, rifampicin, VAN). Of S. aureus isolates 2% were MRSA. Facilities for alcohol hand disinfection at each bed were available in 96% of the ICUs. The numbers of TA90 available were apparently higher than in ICUs in southern Europe and the US, despite a relatively high antibiotic consumption. This may be due to a moderate ecological impact of the used agents and the infection control routines in Swedish ICUs.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12664 (URN)10.1080/00365540310017429 (DOI)
Available from: 2007-10-18 Created: 2007-10-18 Last updated: 2009-08-18
4. Prescription of antibiotic agents in Swedish intensive care units is empiric and adequate
Open this publication in new window or tab >>Prescription of antibiotic agents in Swedish intensive care units is empiric and adequate
Show others...
2007 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 39, no 1, 63-69 p.Article in journal (Refereed) Published
Abstract [en]

Since the prescription of antibiotics in the hospital setting is often empiric, particularly in the critically ill, and therefore fraught with potential error, we analysed the use of antibiotic agents in Swedish intensive care units (ICUs). We examined indications for antibiotic treatment, agents and dosage prescribed among 393 patients admitted to 23 ICUs at 7 tertiary care centres, 11 secondary hospitals and 5 primary hospitals over a 2-week period in November 2000. Antibiotic consumption was higher among ICU patients in tertiary care centres with a median of 84% (range 58-87%) of patients on antibiotics compared to patients in secondary hospitals (67%, range 35-93%) and in primary hospitals (38%, range 24-80%). Altogether 68% of the patients received antibiotics during the ICU stay compared to 65% on admission. Cefuroxime was the most commonly prescribed antibiotic before and during admission (28% and 24% of prescriptions, respectively). A date for decision to continue or discontinue antibiotic therapy was set in 21% (6/29) of patients receiving prophylaxis, in 8% (16/205) receiving empirical treatment and in 3% (3/88) when culture-based therapy was given. No correlation between antibiotic prescription and laboratory parameters such as CRP levels, leukocyte and thrombocyte counts, was found. The treatment was empirical in 64% and prophylactic in 9% of cases. Microbiological data guided prescription more often in severe sepsis (median 50%, range 40-60% of prescriptions) than in other specified forms of infection (median 32%, range 21-50%). The empirically chosen antibiotic was found to be active in vitro against the pathogens found in 55 of 58 patients (95%) with a positive blood culture. This study showed that a high proportion of ICU patients receive antimicrobial agents and, as expected, empirical-based therapy is more common than culture-based therapy. Antibiotics given were usually active in vitro against the pathogen found in blood cultures. We ascribe this to a relatively modest antibiotic resistance problem in Swedish hospitals.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12665 (URN)10.1080/00365540600740504 (DOI)
Available from: 2007-10-18 Created: 2007-10-18 Last updated: 2009-08-18
5. Antibiotic susceptibility patterns and clones of Pseudomonas aeruginosa in Swedish ICUs
Open this publication in new window or tab >>Antibiotic susceptibility patterns and clones of Pseudomonas aeruginosa in Swedish ICUs
Show others...
2008 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 40, no 6-7, 487-494 p.Article in journal (Refereed) Published
Abstract [en]

Pseudomonas aeruginosa is 1 of the bacteria most adaptive to anti-bacterial treatment. Previous studies have shown nosocomial spread and transmission of clonal strains of P. aeruginosa in European hospitals. In this study we investigated antibiotic susceptibility and clonality in 101 P. aeruginosa isolates from 88 patients admitted to 8 Swedish ICUs during 2002. We also compared phenotypes and genotypes of P. aeruginosa and carried out cluster analysis to determine if phenotypic data can be used for surveillance of clonal spread. All isolates were collected on clinical indication as part of the NPRS II study in Sweden and were subjected to AFLP analysis for genotyping. 68 isolates with unique genotypes were found. Phenotyping was performed using MIC values for 5 anti-pseudomonal agents. Almost 6% of the isolates were multi-drug resistant (MDR), and this figure rose to almost 8% when intermediate isolates were also included. We found probable clonal spread in 9 cases, but none of them was found to be an MDR strain. Phenotypical cluster analysis produced 40 clusters. Comparing partitions did not demonstrate any significant concordance between the typing methods. The conclusion of our study is that cross-transmission and clonal spread of MDR P. aeruginosa does not present a clinical problem in Swedish ICUs, but probable cross-transmission of non-MDR clones indicate a need for improved hygiene routines bedside. The phenotype clusters were not concordant with genotype clusters, and genotyping is still recommended for epidemiological tracking.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12666 (URN)10.1080/00365540701864641 (DOI)
Available from: 2007-10-18 Created: 2007-10-18 Last updated: 2010-01-19

Open Access in DiVA

fulltext(563 kB)1445 downloads
File information
File name FULLTEXT01.pdfFile size 563 kBChecksum SHA-1
8124ef00a17747ad47ca089021c82a1c0c11afd3a397d850d1ffc34a97ac15938a34dfe8
Type fulltextMimetype application/pdf
popular summary(12 kB)112 downloads
File information
File name POPULARSUMMARY01.pdfFile size 12 kBChecksum SHA-1
00435ca1181e49db6602f887cd46767557012badc8db7f5903029ff1c34dc6d27246dc76
Type popularsummaryMimetype application/pdf

By organisation
Department of Clinical and Experimental MedicineFaculty of Health Sciences
Infectious Medicine

Search outside of DiVA

GoogleGoogle Scholar
Total: 1445 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 4786 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf