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Antibiotic policy use amongst junior doctors in a Merseyside hospital
Letters to the Editor
pneumoniae) colonization by ESBLPE at time of admission in the ICU has been reported.3,4,6 Patients colonized on admission may have acquired their ESBPLE in the community6 or nursing home.7 On the other hand, there is a risk of spread of ESBPLE out of the ICU.4 Nevertheless, a recent study,8 concluded that patients colonized by multiresistant Klebsiella spp. can be accommodated in communitybased elderly care facilities with little fear of spread to other residents. In our study, the rate of infection was lower than previously reported,3,4 and may be explained in part by the transient nature of colonization. Among risk factors for colonization, duration of stay is the most constantly found.4 For other risk factors, conflicting results have been reported.4 Production of ESBL has now been described in almost all species of Enterobacteriacae.2,3,9 Nevertheless, K. pneumoniae is most commonly associated with ESBL production.2 The coexistence of two or more species in the same patient3,9,10 may allow in vivo transmission of ESBL genes. In our setting, attention should be given to policies of mechanical ventilation and nasogastric tube. Microbiological screening for digestive tract colonization should be carried out in patients transferred from other hospital wards and in patients who had been in hospital previously. N. Moustaoui*, *Microbiology Laboratory, R. Bensghir*, †Surgical Intensive Care Unit, K. Mjahed†, IbnRochd University Hospital, K. Hakim†, ‡Faculty of Sciences BenMsick, R. Aimhand*, Casablanca, Morocco M. Boudouma‡, L. Barrou†, N. Elmdaghri*, M. Benbachir*
239
04. Lucet JC, Chevret S, Decre D et al. Outbreak of multiply resistant Enterobacteriaceae in an intensive care unit: epidemiology and risk factors for acquisition. Clin Infect Dis 1996; 22: 430–436. 05. Jarlier V, Nicolas MH, Fournier G, Philippon A. Extended-broad spectrum beta-lactamase conferring transferable resistance to newer beta-lactam agents in Enterobacteriacae: hospital prevalence and susceptibility patterns. Clin Infect Dis 1988; 10: 867–878. 06. Piroth L, Aubé H, Doise JM, Vincent-Martin M. Spread of extended spectrum beta-lactamase producing Klebsiella pneumoniae: are beta-lactamase inhibitors of therapeutic value? Clin Infect Dis 1998; 27: 76–80. 07. Wiener J, Quinn JP, Bradford PA et al. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA 1999; 281: 6517–6523. 08. Bird J, Browning R, Hobson RP, MacKenzie FM, Brand J, Gould IM. Multiply resistant Klebsiella pneumoniae: failure of spread in community-based elderly care facilities. J Hosp Infect 1998; 40: 243–247. 09. Marchandin H, Carriere C, Sirot D, Jean-Pierre H, Darbas H. TEM-24 produced by four different species of Enterobacteriaceae including Providencia rettgeri in a single patient. Antimicrob Agents Chemother 1999; 43: 2069–2073. 10. Sirot D, DeChamp C, Chanal C et al. Translocation of antibiotic resistance determinants including an extended-spectrum betalactamase between conjugative plasmids of Klebsiella pneumoniae and Escherichia coli. Antimicrob Agents Chemother 1991; 35: 1576–1581.
doi:10.1053/jhin.2000.0825, available online at http://www.idealibrary.com on
Antibiotic policy use amongst junior doctors in a Merseyside hospital Sir,
Acknowledgement We thank Pr Samia Tahiri for assistance in statistical analysis. References 01. Quin JP. Clinical significance of extended-spectrum beta-lactamases. Eur J Clin Microbiol Infect Dis 1994; 13: 39–42. 02. Emery CL, Weymouth LA. Detection and clinical significance of extended-spectrum beta-lactamase in a tertiary-care medical center. J Clin Microb 1997; 35: 2061–2067. 03. Decré D, Gachot B, Lucet JC, Arlet G, BergogneBerezin E, Régnier B. Clinical and bacteriologic epidemiology of extended spectrum beta-lactamase producing strains of Klebsiella pneumoniae in a medical intensive care unit. Clin Infect Dis 1998; 27: 834–844.
Antibiotic resistance constitutes a major threat to public health1,2 and is a function of time and use of antibiotics.3 The Department of Health requires that all Trusts implement policies on the management of infections and the appropriate use of antimicrobial drugs,4 however, implementation of a policy does not guarantee compliance. Our Trust antibiotic policy is a comprehensive, 52-page pocket-sized booklet with an index. All doctors receive a copy either in their induction pack or as a separate mailing and all wards are allocated a copy. We conducted a study to assess use of this policy and alternative sources of information amongst our junior doctors. The potential role of ward computers in antimicrobial prescribing was also considered.5
240
Forty-one senior house officers and 24 house officers were interviewed. The average time since qualification was 28 months (range, 4–156) and 61 (94%) had been employed by the Trust for less than two years. A wide range of specialities were represented, namely accident and emergency (6), anaesthetics (4), general medicine (21), critical care medicine (3), general surgery (12), orthopaedics (1), burns and plastics (3), obstetrics and gynaecology (6), paediatrics (6) and psychiatry (3). Results showed that ward copies of the antibiotic policy were used by 51 juniors. Personal copies were received by 50 at induction and one doctor kept a ward copy for his own use. Of these, 24 left it at home because it was inconvenient to carry or never used. Only 19 took it to work, of which 14 kept it in a bag, three left it on a ward, one carried it in his hand and one in a white coat. Indeed only one doctor wore a white coat. The remaining eight had lost their copy. Fifty-six (86%) found the policy useful and a further seven said that they would consider using it in the future. Thirty-three felt that their use had decreased with experience. In total nine doctors, all senior house officers, never used the policy at all. A number of alternative sources of information were used, both alone and in combination. In fact, 27 juniors carried one or more alternatives. However, the policy remained the primary source of information for 43 and the BNF (British National Formulary) for 11, whilst four preferred to liase with microbiology and one with senior doctors. Although only half of the paediatricians used our guidelines, the others used guidelines from the regional children’s hospital preferentially. When questioned about the future role of computer-based policies, opinions were divided. Thirty-one felt that computerization would help but 34 did not. Some felt it would be more convenient and save time wasted locating mislaid policy
Letters to the Editor
copies, whilst others preferred to have a personal copy to hand. In addition, problems of inadequate training and lack of computer terminals were cited. In conclusion, this study raised several interesting points that may change the future mode of implementation of our antibiotic policy. We noted that our system of policy distribution failed a number of juniors (23%), presumably due to lack of communication between departments. Some 66% used the policy as a primary source of information, but fewer carried a copy (29%), while more (78%) used ward copies. Interestingly, it seems that other sources of information were carried more frequently (41%) and that white coats were not generally worn. This latter fact alone may render the pocket booklet a thing of the past. Would ward copies alone be sufficient or does the future lie with a computerized system? Although this thought was met with some trepidation, with increased training and information technology on the wards, this may represent a more realistic and cost-effective alternative. S. J. Harnett, K. D. Allen
Department of Microbiology, Whiston Hospital, Prescot, Merseyside, L35 5DR, UK
References 1. House of Lords Select Committee on Science and Technology. Resistance to Antibiotics and Other Antimicrobial Agents. London Stationery Office, 1998. 2. Wise R, Hart T, Cars O et al. Antimicrobial resistance is a major threat to public health. BMJ 1998; 317: 609–610. 3. Finch RG. Antibiotic resistance. J Antimicrobial Chemother 1998; 42: 125–128. 4. Health Service Circular 1999/049. Resistance to Antibiotics and other Antimicrobial Agents. NHS Executive 1999. 5. Leibovici L, Shraga I, Andreassen S. How do you choose antibiotic treatment? BMJ 1999; 318: 1614–1616.
pneumoniae) colonization by ESBLPE at time of admission in the ICU has been reported.3,4,6 Patients colonized on admission may have acquired their ESBPLE in the community6 or nursing home.7 On the other hand, there is a risk of spread of ESBPLE out of the ICU.4 Nevertheless, a recent study,8 concluded that patients colonized by multiresistant Klebsiella spp. can be accommodated in communitybased elderly care facilities with little fear of spread to other residents. In our study, the rate of infection was lower than previously reported,3,4 and may be explained in part by the transient nature of colonization. Among risk factors for colonization, duration of stay is the most constantly found.4 For other risk factors, conflicting results have been reported.4 Production of ESBL has now been described in almost all species of Enterobacteriacae.2,3,9 Nevertheless, K. pneumoniae is most commonly associated with ESBL production.2 The coexistence of two or more species in the same patient3,9,10 may allow in vivo transmission of ESBL genes. In our setting, attention should be given to policies of mechanical ventilation and nasogastric tube. Microbiological screening for digestive tract colonization should be carried out in patients transferred from other hospital wards and in patients who had been in hospital previously. N. Moustaoui*, *Microbiology Laboratory, R. Bensghir*, †Surgical Intensive Care Unit, K. Mjahed†, IbnRochd University Hospital, K. Hakim†, ‡Faculty of Sciences BenMsick, R. Aimhand*, Casablanca, Morocco M. Boudouma‡, L. Barrou†, N. Elmdaghri*, M. Benbachir*
239
04. Lucet JC, Chevret S, Decre D et al. Outbreak of multiply resistant Enterobacteriaceae in an intensive care unit: epidemiology and risk factors for acquisition. Clin Infect Dis 1996; 22: 430–436. 05. Jarlier V, Nicolas MH, Fournier G, Philippon A. Extended-broad spectrum beta-lactamase conferring transferable resistance to newer beta-lactam agents in Enterobacteriacae: hospital prevalence and susceptibility patterns. Clin Infect Dis 1988; 10: 867–878. 06. Piroth L, Aubé H, Doise JM, Vincent-Martin M. Spread of extended spectrum beta-lactamase producing Klebsiella pneumoniae: are beta-lactamase inhibitors of therapeutic value? Clin Infect Dis 1998; 27: 76–80. 07. Wiener J, Quinn JP, Bradford PA et al. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA 1999; 281: 6517–6523. 08. Bird J, Browning R, Hobson RP, MacKenzie FM, Brand J, Gould IM. Multiply resistant Klebsiella pneumoniae: failure of spread in community-based elderly care facilities. J Hosp Infect 1998; 40: 243–247. 09. Marchandin H, Carriere C, Sirot D, Jean-Pierre H, Darbas H. TEM-24 produced by four different species of Enterobacteriaceae including Providencia rettgeri in a single patient. Antimicrob Agents Chemother 1999; 43: 2069–2073. 10. Sirot D, DeChamp C, Chanal C et al. Translocation of antibiotic resistance determinants including an extended-spectrum betalactamase between conjugative plasmids of Klebsiella pneumoniae and Escherichia coli. Antimicrob Agents Chemother 1991; 35: 1576–1581.
doi:10.1053/jhin.2000.0825, available online at http://www.idealibrary.com on
Antibiotic policy use amongst junior doctors in a Merseyside hospital Sir,
Acknowledgement We thank Pr Samia Tahiri for assistance in statistical analysis. References 01. Quin JP. Clinical significance of extended-spectrum beta-lactamases. Eur J Clin Microbiol Infect Dis 1994; 13: 39–42. 02. Emery CL, Weymouth LA. Detection and clinical significance of extended-spectrum beta-lactamase in a tertiary-care medical center. J Clin Microb 1997; 35: 2061–2067. 03. Decré D, Gachot B, Lucet JC, Arlet G, BergogneBerezin E, Régnier B. Clinical and bacteriologic epidemiology of extended spectrum beta-lactamase producing strains of Klebsiella pneumoniae in a medical intensive care unit. Clin Infect Dis 1998; 27: 834–844.
Antibiotic resistance constitutes a major threat to public health1,2 and is a function of time and use of antibiotics.3 The Department of Health requires that all Trusts implement policies on the management of infections and the appropriate use of antimicrobial drugs,4 however, implementation of a policy does not guarantee compliance. Our Trust antibiotic policy is a comprehensive, 52-page pocket-sized booklet with an index. All doctors receive a copy either in their induction pack or as a separate mailing and all wards are allocated a copy. We conducted a study to assess use of this policy and alternative sources of information amongst our junior doctors. The potential role of ward computers in antimicrobial prescribing was also considered.5
240
Forty-one senior house officers and 24 house officers were interviewed. The average time since qualification was 28 months (range, 4–156) and 61 (94%) had been employed by the Trust for less than two years. A wide range of specialities were represented, namely accident and emergency (6), anaesthetics (4), general medicine (21), critical care medicine (3), general surgery (12), orthopaedics (1), burns and plastics (3), obstetrics and gynaecology (6), paediatrics (6) and psychiatry (3). Results showed that ward copies of the antibiotic policy were used by 51 juniors. Personal copies were received by 50 at induction and one doctor kept a ward copy for his own use. Of these, 24 left it at home because it was inconvenient to carry or never used. Only 19 took it to work, of which 14 kept it in a bag, three left it on a ward, one carried it in his hand and one in a white coat. Indeed only one doctor wore a white coat. The remaining eight had lost their copy. Fifty-six (86%) found the policy useful and a further seven said that they would consider using it in the future. Thirty-three felt that their use had decreased with experience. In total nine doctors, all senior house officers, never used the policy at all. A number of alternative sources of information were used, both alone and in combination. In fact, 27 juniors carried one or more alternatives. However, the policy remained the primary source of information for 43 and the BNF (British National Formulary) for 11, whilst four preferred to liase with microbiology and one with senior doctors. Although only half of the paediatricians used our guidelines, the others used guidelines from the regional children’s hospital preferentially. When questioned about the future role of computer-based policies, opinions were divided. Thirty-one felt that computerization would help but 34 did not. Some felt it would be more convenient and save time wasted locating mislaid policy
Letters to the Editor
copies, whilst others preferred to have a personal copy to hand. In addition, problems of inadequate training and lack of computer terminals were cited. In conclusion, this study raised several interesting points that may change the future mode of implementation of our antibiotic policy. We noted that our system of policy distribution failed a number of juniors (23%), presumably due to lack of communication between departments. Some 66% used the policy as a primary source of information, but fewer carried a copy (29%), while more (78%) used ward copies. Interestingly, it seems that other sources of information were carried more frequently (41%) and that white coats were not generally worn. This latter fact alone may render the pocket booklet a thing of the past. Would ward copies alone be sufficient or does the future lie with a computerized system? Although this thought was met with some trepidation, with increased training and information technology on the wards, this may represent a more realistic and cost-effective alternative. S. J. Harnett, K. D. Allen
Department of Microbiology, Whiston Hospital, Prescot, Merseyside, L35 5DR, UK
References 1. House of Lords Select Committee on Science and Technology. Resistance to Antibiotics and Other Antimicrobial Agents. London Stationery Office, 1998. 2. Wise R, Hart T, Cars O et al. Antimicrobial resistance is a major threat to public health. BMJ 1998; 317: 609–610. 3. Finch RG. Antibiotic resistance. J Antimicrobial Chemother 1998; 42: 125–128. 4. Health Service Circular 1999/049. Resistance to Antibiotics and other Antimicrobial Agents. NHS Executive 1999. 5. Leibovici L, Shraga I, Andreassen S. How do you choose antibiotic treatment? BMJ 1999; 318: 1614–1616.