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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR64

Quinolone resistance patterns in a large district general hospital

By C. Curtis,* J. F. Marriott and K. A. Wilson

Introduction Antibiotic resistance is recognised as a major problem in health care.1 Recent recommendations to curb increasing resistance patterns include the use of strategic systems for resistance surveillance.1 However, in many secondary health care sites, resource and technological barriers compromise the achievement of this aim.
The present study describes the use of data from a national pilot of an electronic patient record system in a large district general to assess patterns of quinolone antibiotic use and resistance.

Method A systematic drug use review was conducted for quinolone antibiotic administered from January and October, 1999, inclusive. Data was generated by a hospital integrated information system (Medical Information Technology Inc, Massachusetts, united States), which facilitates the correlation of patient microbiological testing procedures with prescribing.

Focal points

  • Overall theme: Testing the viability of monitoring antibiotic use and resistance patterns using an integrated electronic patient record system
  • Rationale: To investigate whether best practice prescribing is applied to quinolone use in secondary care
  • Study design: Systematic drug use review utilising electronic linkage at patient level to microbiological testing records
  • Outcomes: Quinolones are frequently prescribed without microbiological justification; targets for focused prescribing education were identified
  • Future work: This study forms part of a larger investigation into antibiotic prescribing patterns that aims to develop improved methods to optimise antibiotic use

Results During the study period, 879 patients were prescribed a quinolone antibiotic. Almost one third (29 per cent) of these cases were in the elderly care specialty. Together with general surgery, outpatients and general medicine, these specialties accounted for 633 (72 per cent) of patients treated with a quinolone.
Microbiological sensitivity testing was undertaken in only 568 (65 per cent) of the cases. Organisms were isolated from only 311 (55 per cent) of the samples and of these 283 (91 per cent) were sensitive to a quinolone. However, 12 isolates (4 per cent) were of intermediate resistance and 16 (5 per cent) were quinolone resistant (MIC >2µg/mL).
Nearly half (44 per cent) of the resistant organisms belonged to Pseudomonas spp. The resistant or partially resistant isolates arose from patients in elderly care (43 per cent), general medical (29 per cent), general surgical (18 per cent) and orthopaedic (11 per cent) locations.

Discussion Recent national advice has indicated that antibiotic use and resistance patterns should be audited regularly and that prescribers should be provided with appropriate education.1 Currently, time constraints and limitations of information technology systems render such aspirations impractical. However, the patient information system utilised in the present study facilitated rapid and complete data gathering.
The results indicate that, despite advice to the contrary, quinolones are often prescribed "blind". Moreover, resistance to quinolones is encountered, albeit at present only in a relatively small number of patients. If this behaviour is duplicated in other hospitals, then clinical pharmacists should ensure that they check whether sensitivity testing has been carried out when they review prescriptions for quinolone antibiotics.
These problems were most prevalent in elderly care, possibly because of longer than average stays during which serious infection may be acquired. It is suggested that targeting antibiotic prescribing in the elderly might therefore result in the greatest impact upon drug expenditure and increased resistance patterns.

Pharmacy practice group, Aston pharmacy school, Aston university, Birmingham B4 7ET; *Pharmacy department, Queens hospital, Burton on Trent DE13 0RB

References

1. Standing Medical Advisory Committee. Quinolone resistance patterns in a large district general hospital. The path of least resistance. Main report. London: Department of Health; 1998.