Unintended Consequences of Fluoroquinolone Stewardship: Impact on Overall Antimicrobial Use Data and Implications for Benchmarking

An antimicrobial stewardship initiative to reduce fluoroquinolone (FQ) use in targeted diagnosis-related groups (DRGs) across a large healthcare system was launched due to increasing FQ resistance and FDA warnings on the adverse events associated with FQ use. In community-acquired pneumonia (CAP), interventions to change prescribing from FQs to beta-lactams plus an atypical agent (combination therapy) resulted in a doubling of days of therapy (DOT) for that indication as measured by 1000 patient-days. Combination regimens, however, may provide patient safety and antibiotic resistance benefits that are not captured by DOT metrics alone.

This multicenter, retrospective study examined the relationship between utilization of FQ-sparing combination therapy for patients with CAP and the associated impact on antibiotic stewardship metrics. The initiative resulted in a drastic 40% reduction in overall FQ use (P <.001); however, overall antibiotic consumption did not change. The decrease in FQ utilization was inversely proportional to increases in combination treatment (P <.001), as well as in individual usage of doxycycline (P <.001). Change to combination therapy resulted in greater overall antibiotic DOT, which were likely offset by avoiding and decreasing antibiotic usage outside of CAP and chronic obstructive pulmonary disease, leading to no change between 2016 and 2017.

Whereas this intervention was considered appropriate for patient safety and resistance reasons, unintended impact on standard consumption metrics should be considered when comparing use within or across institutions. Also, examination of the impact on overall DOT in additional disease states and at the facility-specific level is needed. The effects of selective susceptibility reports for FQs remain to be seen, as only a short period after was analyzed. The perceived negative effect on antimicrobial consumption associated with combination therapy may be especially pronounced at small institutions or when assessing unit-specific utilization.

Source: Green S, Chapin R. IDWeek 2018. Abstract 215.

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