Professional Documents
Culture Documents
tors for the selection of antibiotic resistance can be variously made. Examples
include (1) patients with any clinical specimen exhibiting the resistance phenotype
under study, (2) patients with unequivocally significant isolates (e.g., patients with
bacteremia), and (3) patients with an infection defined by clinical criteria (thereby
excluding patients whose isolates represent
colonization rather than true infection).
Each of these definitions has limitations. For each patient from whom a clinical specimen is obtained that harbors an
antibiotic-resistant organism, there may
be 25 other patients with asymptomatic
colonization (especially of the gastrointestinal tract). Colonized patients may be erroneously classified as control patients,
thereby leading to a potential underestimation of the risk provided by use of certain antibiotics. Therefore, it could be argued that, in an ideal case-control study
that examines the risk factors for selection
of antibiotic resistance, case patients
would be defined as all patients colonized
with the antibiotic-resistant organism under study (table 1). In practice, such an
approach would require systematic prospective surveillance for resistant organisms (e.g., by periodic rectal or nose swabs
of at-risk patients).
The acquisition of antibiotic-resistant
bacteria within our hospitals represents
the combined result of the selection of re-
Table 1.
The ideal case-control study for examination of the risk factors for the acquisition of antibiotic-resistant organisms.
Variable
Ideal study
Usual study
All patients colonized or infected with the antibioticresistant organism under study
All patients with clinical isolates of the antibiotic-resistant organism under study
Molecular epidemiological
analysis
No intervention
Analyses
Intervention
Figure 1. Acquisition of antibiotic-resistant bacteria from either in vivo selection by antibiotic use or horizontal transmission of genotypically
identical organisms. An unknown component of horizontal transmission is facilitated by antibiotics that increase the density of colonization with
resistant organisms.
studies that have assessed antibioticresistant organisms are the Acute Physiology and Chronic Health Evaluation
(APACHE) III score [8] and the Pitt bacteremia index [9]. It should be noted that
the APACHE III score is only applicable to patients in ICUs, and, although
it is a predictor of mortality, it may not
necessarily be a predictor of colonization or infection with antibiotic-resistant
organisms.
Given these comments about the selection of case and control patients (summarized in table 1), how should we apply
the results of case-control studies that explore risk factors for acquisition of antibiotic-resistant organisms? Kollef et al.
[10] have recently demonstrated that the
use of inadequate empiric antibiotic therapy in patients hospitalized in ICUs was
associated with increased mortality. Inadequate empiric antibiotic therapy was
most frequently caused by unsuspected
antibiotic resistance. Therefore, intuitively,
it seems right to do all we can to prevent
antibiotic resistance, even if it means restriction of the use of certain antibiotics.
However, we should put such policies in
practice only after evaluation of the big
picture. The adverse effects on the outcome of antibiotic resistance in one organism need to be compared with the adverse effects of increased resistance in
other organisms if antibiotic-use patterns
References
1. Donskey CJ, Chowdhry TK, Hecker MT, et al.
Effect of antibiotic therapy on the density of