Skip to content

Research at St Andrews

Changes in resistance among coliform bacteraemia associated with a primary care antimicrobial stewardship intervention: a population-based interrupted time series study

Research output: Contribution to journalArticle

Author(s)

Virginia Hernandez-Santiago, Peter G. Davey, Dilip Nathwani, Charis A. Marwick, Bruce Guthrie

School/Research organisations

Abstract

Background:  Primary care antimicrobial stewardship interventions can improve antimicrobial prescribing, but there is less evidence that they reduce rates of resistant infection. This study examined changes in broad-spectrum antimicrobial prescribing in the community and resistance in people admitted to hospital with community-associated coliform bacteraemia associated with a primary care stewardship intervention.

Methods and findings:  Segmented regression analysis of data on all patients registered with a general practitioner in the National Health Service (NHS) Tayside region in the east of Scotland, UK, from 1 January 2005 to 31 December 2015 was performed, examining associations between a primary care antimicrobial stewardship intervention in 2009 and primary care prescribing of fluoroquinolones, cephalosporins, and co-amoxiclav and resistance to the same three antimicrobials/classes among community-associated coliform bacteraemia. Prescribing outcomes were the rate per 1,000 population prescribed each antimicrobial/class per quarter. Resistance outcomes were proportion of community-associated (first 2 days of hospital admission) coliform (Escherichia coli, Proteus spp., or Klebsiella spp.) bacteraemia among adult (18+ years) patients resistant to each antimicrobial/class. 11.4% of 3,442,205 oral antimicrobial prescriptions dispensed in primary care over the study period were for targeted antimicrobials. There were large, statistically significant reductions in prescribing at 1 year postintervention that were larger by 3 years postintervention when the relative reduction was −68.8% (95% CI −76.3 to −62.1) and the absolute reduction −6.3 (−7.6 to −5.2) people exposed per 1,000 population per quarter for fluoroquinolones; relative −74.0% (−80.3 to −67.9) and absolute reduction −6.1 (−7.2 to −5.2) for cephalosporins; and relative −62.3% (−66.9 to −58.1) and absolute reduction −6.8 (−7.7 to −6.0) for co-amoxiclav, all compared to their prior trends. There were 2,143 eligible bacteraemia episodes involving 2,004 patients over the study period (mean age 73.7 [SD 14.8] years; 51.4% women). There was no increase in community-associated coliform bacteraemia admissions associated with reduced community broad-spectrum antimicrobial use. Resistance to targeted antimicrobials reduced by 3.5 years postintervention compared to prior trends, but this was not statistically significant for co-amoxiclav. Relative and absolute changes were −34.7% (95% CI −52.3 to −10.6) and −63.5 (−131.8 to −12.8) resistant bacteraemia per 1,000 bacteraemia per quarter for fluoroquinolones; −48.3% (−62.7 to −32.3) and −153.1 (−255.7 to −77.0) for cephalosporins; and −17.8% (−47.1 to 20.8) and −63.6 (−206.4 to 42.4) for co-amoxiclav, respectively. Overall, there was reversal of a previously rising rate of fluoroquinolone resistance and flattening of previously rising rates of cephalosporin and co-amoxiclav resistance. The limitations of this study include that associations are not definitive evidence of causation and that potential effects of underlying secular trends in the postintervention period and/or of other interventions occurring simultaneously cannot be definitively excluded.

Conclusions:  In this population-based study in Scotland, compared to prior trends, there were very large reductions in community broad-spectrum antimicrobial use associated with the stewardship intervention. In contrast, changes in resistance among coliform bacteraemia were more modest. Prevention of resistance through judicious use of new antimicrobials may be more effective than trying to reverse resistance that has become established.
Close

Details

Original languageEnglish
Article numbere1002825
Number of pages19
JournalPLoS Medicine
Volume16
Issue number6
DOIs
Publication statusPublished - 7 Jun 2019

Discover related content
Find related publications, people, projects and more using interactive charts.

View graph of relations

Related by author

  1. Exploring the training and scope of practice of GPs in England, Germany and Spain

    Glonti, K., Struckmann, V., Alconada, A., Pettigrew, L. M., Hernandez-Santiago, V., Minue, S., Risso-Gill, I., McKee, M. & Legido-Quigley, H., Mar 2019, In : Gaceta Sanitaria. 33, 2, p. 148-155

    Research output: Contribution to journalArticle

  2. Short-course versus long-course therapy of the same antibiotic for community-acquired pneumonia in adolescent and adult outpatients

    López-Alcalde, J., Rodriguez-Barrientos, R., Redondo-Sánchez, J., Muñoz-Gutiérrez, J., Molero García, J. M., Rodríguez-Fernández, C., Heras-Mosteiro, J., Marin-Cañada, J., Casanova-Colominas, J., Azcoaga-Lorenzo, A., Hernandez Santiago, V. & Gómez-García, M., 6 Sep 2018, In : Cochrane Database of Systematic Reviews. 9, 37 p., CD009070.

    Research output: Contribution to journalReview article

  3. Has primary care antimicrobial use really been increasing? Comparison of changes in different prescribing measures for a complete geographic population 1995–2014

    Neilly, M. D. J., Guthrie, B., Hernandez Santiago, V., Vadiveloo, T., Donnan, P. T. & Marwick, C. A., 1 Oct 2017, In : Journal of Antimicrobial Chemotherapy. 72, 10, p. 2921-2930 10 p.

    Research output: Contribution to journalArticle

  4. Antibioticos en atención primaria. Como hemos llegado hasta aquí?

    Molero, J. M. & Hernandez Santiago, V., 1 Jun 2017, In : AMF. 13, 6, p. 327-333 7 p.

    Research output: Contribution to journalArticle

  5. Effectiveness of an intervention for improving drug prescription in primary care patients with multimorbidity and polypharmacy: study protocol of a cluster randomized clinical trial (Multi-PAP project)

    Prados-Torres, A., del Cura-González, I., Prados-Torres, D., López-Rodríguez, J. A., Leiva-Fernández, F., Calderón-Larrañaga, A., López-Verde, F., Gimeno-Feliu, L. A., Escortell-Mayor, E., Pico-Soler, V., Sanz-Cuesta, T., Bujalance-Zafra, M. J., Morey-Montalvo, M., Boxó-Cifuentes, J. R., Poblador-Plou, B., Fernández-Arquero, J. M., González-Rubio, F., Ramiro-González, M. D., Coscollar-Santaliestra, C., Martín-Fernández, J. & 7 others, Barnestein-Fonseca, M. P., Valderas-Martínez, J. M., Marengoni, A., Muth, C., Multi-PAP Group, Hernández-Santiago, V. & Azcoaga-Lorenzo, A., 27 Apr 2017, In : Implementation Science. 12, 10 p., 54.

    Research output: Contribution to journalArticle

Related by journal

  1. Mortality, ethnicity, and country of birth on a national scale, 2001–2013: a retrospective cohort (Scottish Health and Ethnicity Linkage Study)

    Bhopal, R. S., Gruer, L., Cezard, G., Douglas, A., Steiner, M. F. C., Millard, A., Buchanan, D., Katikireddi, S. V. & Sheikh, A., 1 Mar 2018, In : PLoS Medicine. 15, 3, 18 p., e1002515.

    Research output: Contribution to journalArticle

  2. Raltegravir-intensified initial antiretroviral therapy in advanced HIV disease in Africa: a randomised controlled trial

    O'Hare, B. A-M. & REALITY Trial Team, 4 Dec 2018, In : PLoS Medicine. 15, 12, p. 1-20 20 p., e1002706.

    Research output: Contribution to journalArticle

  3. Risk of Cardiovascular Disease and Total Mortality in Adults with Type 1 Diabetes: Scottish Registry Linkage Study

    Livingstone, S. J., Looker, H. C., Hothersall, E. J., Wild, S. H., Lindsay, R. S., Chalmers, J., Cleland, S., Leese, G. P., McKnight, J., Morris, A. D., Pearson, D. W. M., Peden, N. R., Petrie, J. R., Philip, S., Sattar, N., Sullivan, F. & Colhoun, H. M., 1 Oct 2012, In : PLoS Medicine. 9, 10, e1001321.

    Research output: Contribution to journalArticle

  4. Examining the "Urban Advantage'' in Maternal Health Care in Developing Countries

    Matthews, Z., Channon, A., Neal, S., Osrin, D., Madise, N. & Stones, W., Sep 2010, In : PLoS Medicine. 7, 9, 7 p., 1000327.

    Research output: Contribution to journalEditorial

ID: 259345273

Top