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This result might be construed to mean that reduction in third-generation cephalosporin use is completely ineffective in the control of VRE. However, the prevalence of VRE is affected by multiple factors, including concurrent infection-control interventions and concurrent trends in the use of antibiotics with antianaerobic bacterial activity [ 12 , 13 ]. More institutions need to publish their experience with alteration in cephalosporin use and its effect on VRE prevalence in order for a clearer understanding of this relationship to emerge.

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Third-generation cephalosporin use has also been associated with infection with methicillin-resistant Staphylococcus aureus MRSA in some case-control studies [ 15 ]. Gram-negative bacilli. In contrast to the scenario with gram-positive organisms, there does appear to be a clear-cut relationship between the use of third-generation cephalosporin antibiotics and colonization or infection with certain multidrug-resistant gram-negative bacilli.

This has been demonstrated in studies correlating total hospital antibiotic consumption with hospital-wide antibiotic resistance rates, in case-control studies, and in studies assessing the effects of limitation of cephalosporins on hospital-wide antibiotic resistance rates. Quale and Landman and their colleagues [ 17—20 ] have published a number of significant papers assessing outbreaks of multiresistant gram-negative bacilli in multiple hospitals in Brooklyn, New York.

Furthermore, total hospital use of cephalosporins plus aztreonam was directly correlated with the prevalence of ESBL-producing K. Several case-control studies have also shown a relationship between prior use of third-generation cephalosporins and subsequent colonization or infection with ESBL-producing organisms [ 21—25 ]. Studies that have not shown this association have generally been underpowered or have examined a focal monoclonal outbreak, associated with poor infection control [ 26 ]. Several studies have used education of prescribers as a means of reducing cephalosporin use and have observed reductions in the rates of ESBL production by gram-negative organisms [ 27 , 28 ].

More forcefully, Rahal et al. Following restriction, neither ceftriaxone nor cefuroxime was used for CAP in their institution, and the use of a cephalosporin for any condition other than pediatric infection, meningitis, gonococcal infection, or spontaneous bacterial peritonitis was allowed only after approval from the hospital's infectious disease service.

Although it has been widely noted that imipenem resistance in P.

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A plethora of case-control studies have associated C. There is a potential connection between prior quinolone use and colonization or infection with MRSA. Several case-control studies have shown that prior receipt of a quinolone was associated with subsequent MRSA infection [ 40—43 ]. In a study of 10 urban teaching hospitals across the United States over a prolonged period, an overall decrease in susceptibility of S.

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This coincided with an increase in quinolone use in 9 of the 10 institutions. It is noteworthy that the majority of MRSA strains are now also quinolone-resistant, and hence selection of such strains by quinolone use is biologically plausible. It is interesting that exposure of clinical isolates of MRSA to subinhibitory concentrations of quinolones induces the production of fibronectin-binding proteins and increases the adhesion of staphylococci to fibronectin-coated surfaces [ 45 , 46 ].

There are few data on the relationship between prior quinolone use and colonization or infection with VRE. However, Lautenbach et al. There is little doubt that patients who develop an infection with a gram-negative bacillus and who have previously received a quinolone will have an increased risk of infection with a quinolone-resistant strain.

This has been demonstrated in patients who have received quinolones as prophylaxis against infections with gram-negative bacilli while neutropenic and while receiving quinolones as prophylaxis against spontaneous bacterial peritonitis [ 47—49 ]. Additionally, prior quinolone use is a risk factor for subsequent infection with quinolone-resistant, ESBL-producing organisms [ 50 , 51 ]. The multihospital studies in Brooklyn did not find a relationship between hospitals' rate of use of quinolones and the number of infections with ceftazidime-resistant K.

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However, case-control studies have identified prior quinolone use as a risk factor for infection with ESBL-producing Klebsiella species and Escherichia coli in nursing homes and nosocomial Acinetobacter infections in an ICU [ 52 , 53 ]. A major concern worldwide has been the increasing resistance of P. Quinolones represent an important option for treatment of P. However, increasing quinolone use for indications other than P. Zervos et al. Of note, in the single institution in which there was a reduction in quinolone use over time, there was also an improvement in the quinolone susceptibility of isolates.

For many years, quinolone use has been regarded as creating little risk of C. However, recent case-control studies have concluded that use of quinolones may indeed be a risk factor for nosocomial C. It remains to be seen whether quinolones with enhanced antianaerobic bacterial activity increase or decrease the risk of nosocomial C. No two hospitals are alike in the intensity of antibiotic use or adequacy of and adherence to infection control procedures. Numerous confounding factors may make extrapolation of results from one particular hospital or region to another misleading.

In contrast, cephalosporin and quinolone use has been linked more frequently to collateral damage in the form of antibiotic-resistant superinfections table 1. Such infections include those with multiresistant gram-positive and gram-negative bacteria as well as C. Oxford University Press is a department of the University of Oxford.

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Control group selection is an important but neglected issue in studies of antibiotic resistance [letter]. Search ADS. Methodological principles of case-control studies that analyzed risk factors for antibiotic resistance: a systematic review. Control-group selection importance in studies of antimicrobial resistance: examples applied to Pseudomonas aeruginosa , Enterococci, and Escherichia coli. Looking for risk factors for the acquisition of antibiotic resistance: a 21st-century approach.

Parallel analysis of individual and aggregated data on antibiotic exposure and resistance in gram-negative bacilli. Effect of parenteral antibiotic administration on the establishment of colonization with vancomycin-resistant Enterococcus faecium in the mouse gastrointestinal tract. Cephalosporins as risk factor for nosocomial Enterococcus faecalis bacteremia. A matched case-control study. Third-generation cephalosporins and vancomycin as risk factors for postoperative vancomycin-resistant enterococcus infection. Vancomycin-resistant enterococci in intensive care units: high frequency of stool carriage during a non-outbreak period.

A case-control study to detect modifiable risk factors for colonization with vancomycin-resistant enterococci. The effect of vancomycin and third-generation cephalosporins on prevalence of vancomycin-resistant enterococci in US adult intensive care units. Changes in the prevalence of vancomycin-resistant enterococci in response to antimicrobial formulary interventions: impact of progressive restrictions on use of vancomycin and third-generation cephalosporins.

Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients. The control of hyperendemic glycopeptide-resistant Enterococcus spp. Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime-resistant Klebsiella pneumoniae following changes in a hospital antibiotic formulary.

Citywide clonal outbreak of multiresistant Acinetobacter baumannii and Pseudomonas aeruginosa in Brooklyn, NY: the preantibiotic era has returned. Endemic carbapenem-resistant Acinetobacter species in Brooklyn, New York: citywide prevalence, interinstitutional spread, and relation to antibiotic usage. Antimicrobial resistance in Enterobacteriaceae in Brooklyn, NY: epidemiology and relation to antibiotic usage patterns. Outbreak of a multiresistant Klebsiella pneumoniae strain in an intensive care unit: antibiotic use as risk factor for colonization and infection. Ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection: a case-control and molecular epidemiologic investigation.

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Ceftazidime-resistant Klebsiella pneumoniae bloodstream infection in children with febrile neutropenia.