Restricted antimicrobial prescribing in an area of highly prevalent antimicrobial resistance.

ABSTRACT

OBJECTIVE: To assess the predictive value for infection with multidrug-resistant organisms (MDROs) of reasons for empirical prescription of restricted antibiotics (rABX), in a setting with high resistance rates. METHODS: We prospectively studied all rABX prescriptions in a 550-bed tertiary teaching hospital from April 15 to June 14, 2018 and from September 1 to October 30, 2018. Prescribing physicians had to justify their decision by choosing one or more prespecified reasons. RESULTS: We reviewed 172 empirical prescriptions of rABX, which accounted for 67.2% of all rABX prescriptions. Stated reasons for empirical prescription of rABX were recent hospitalization (72.7%), escalation due to non-response to previous antimicrobials (47.7%), treatment for severe sepsis/septic shock (45.9%), escalation due to recurrence or deterioration (22.1%), prior MDRO infection (12.8%), and prior MDRO colonization (7.6%). Empirical treatment for septic shock or severe sepsis was the only significant predictor of MDRO isolation (OR=5.26, 95% CI 1.5-18.4, P=0.009), while recent hospitalization had a high negative predictive value for MDRO (97.4%). Fourteen per cent of microbiologically documented infections were associated with MDROs resistant to the prescribed rABX. CONCLUSIONS: Empirical treatment for severe sepsis or septic shock was the only independent predictor of MDRO isolation. Recent hospitalization had a high negative predictive value for MDRO infection. The isolation of pathogens resistant to the prescribed rABX suggests that in a setting with widespread antimicrobial resistance, it could be difficult to reduce the empirical use of rABX without risking inadequate treatment.