E-drug: Widely varying antibiotic use
---------------------------------------------------------------------
[Copied as fair use. HH]
BMJ 2003;327:1128 (15 November)
http://bmj.com/cgi/collection/International_health%3Anonclinical?ecoll
Antibiotic use varies widely across intensive care units
Abergavenny Roger Dobson
Big international differences in antibiotic use in hospital intensive care
units have been found by researchers.
The researchers, who surveyed more than 200 intensive care units in
34 countries, say the results show that policies on optimal antibiotic
prescribing for critically ill patients are urgently needed.
"We documented a wide variation in antibiotic prescribing practice for
bacteraemia in intensive care unit patients that is too wide to fit the
hypothesis that all observed approaches are appropriate," said the
authors of a report published online in the Journal of Antimicrobial
Chemotherapy (www.jac.oupjournals.org), in advance of the print
version.
They continued: "This survey is the first to document and confirm our
impression that a large variability in prescribing practice does indeed
exist. The wide variability in antibiotic prescribing patterns suggests
an urgent need to produce high-quality evidence to identify optimal
antibiotic prescribing policies for bacteraemia in the critically ill
patient. No randomised, prospective clinical trials exist to guide
prescribing practice, and the few available observational studies do
not offer clear advice.''
The authors, from the United Kingdom and Italy, assessed the
variation in current antibiotic practice using a questionnaire sent to
membership lists of national and international intensive care
societies. Of the units that took part, 214 were European, 21
Australasian, and 10 Latin American.
For countries with at least 10 participating centres, the percentage of
units using long courses of antibiotics (defined as 10 or more days)
varied considerably. For treating primary bacteraemia, the range was
4% to 75%; for nosocomial pneumonia related bacteraemia, 17% to
88%; and for peritonitis related bacteraemia, 20% to 94%.
The authors also found a significant inverse association between
specialist input and the duration of antibiotic treatment for all types of
bacteraemia.
"We were interested to find a strong effect relating to country and
specialist input, though these two were strongly interconnected with
high-level specialist input in the Netherlands and the UK contrasted
by negligible direct involvement in Italy," said the authors.
"French and Spanish doctors are often horrified at how we in the UK
use much shorter courses of antibiotics. I am equally horrified when I
see how long they use them for," said one of the authors, Mervyn
Singer, professor of intensive care medicine at University College
London.
"The question is," he told the BMJ, "does the longer course breed
resistance problems? The counter argument, of course, is, does the
shorter course lead to more relapses and also an increased risk of
resistance due to incomplete eradication?"
"The general UK philosophy is that shorter is better," said Professor
Singer, "and we certainly don't have compared with a lot of
mainland Europe and the US a lot of the multiresistant gram
negative problems that they see, nor the fungal problems. In America,
they are now reporting that 20% of positive cultures incubated from
the critically ill patient are fungal, whereas in the UK we are looking at
a couple of per cent. I would like to see a definitive, large prospective
randomised trial of short versus long duration antibiotics."
--
To send a message to E-Drug, write to: e-drug@healthnet.org
To subscribe or unsubscribe, write to: majordomo@healthnet.org
in the body of the message type: subscribe e-drug OR unsubscribe e-drug
To contact a person, send a message to: e-drug-help@healthnet.org
Information and archives: http://www.essentialdrugs.org/edrug