A Nonrestrictive Approach to Fluoroquinolone Stewardship at Two Community Hospitals

Abstract

Background: Fluoroquinolones are one of the most prescribed antimicrobials in the United States and have been increasingly used in inpatient and outpatient settings to treat various infectious diseases syndromes. Due to the unwanted collateral effects on antibiotic resistance, poor susceptibility rates among Gram-negative pathogens, and adverse effects, fluoroquinolones are often targeted by hospital antimicrobial stewardship programs to prevent overutilization. This study describes the association of nonrestrictive antimicrobial stewardship interventions at 2 nonacademic community hospitals on levofloxacin utilization, prescribing patterns on alternative antibiotics, and Pseudomonas aeruginosa nonsusceptibility rates to levofloxacin.

Methods: Nonrestrictive antimicrobial stewardship interventions included monitoring and reporting of fluoroquinolone susceptibility trends to physician groups, performing medication use evaluations of levofloxacin accompanied with prescriber detailing, daily prospective audit and feedback, implementation of beta-lactam-based institutional guidelines for empiric therapy in various infectious disease syndromes, review and adjustment of electronic medical record order sets containing fluoroquinolones, and intensive prescriber education. No preauthorization of levofloxacin was used during this study period. Antibiotic utilization data were collected for the time periods of August 2015 through January 2021. Correlation between levofloxacin and other broad-spectrum antibiotc use was investigated as well as the impact on Pseudomonas aeruginosa levofloxacin nonsusceptibility rates.

Results: Both hospitals showed an overall downward trend in the prescribing of levofloxacin during the time period of August 2015 to January 2021. There was a significant negative correlation between monthly ceftriaxone and levofloxacin days of therapy for both hospitals (P < .0001). There was a positive correlation between levofloxacin days of therapy and P aeruginosa nonsusceptibility (P < .02 at both hospitals).

Conclusions: Our results demonstrate that a nonrestrictive approach to fluoroquinolone stewardship interventions had a significant impact on reducing levofloxacin utilization, increasing ceftriaxone utilization, and improving P aeruginosa levofloxacin susceptibility.

Keywords: antibiotic stewardship; antimicrobial resistance; antimicrobial stewardship program; fluoroquinolone stewardship; levofloxacin.

Figure 1.

Broad-spectrum antibiotic (ABX) days of therapy (DOT)/1000 patient-days (PD) by every 6 months: (A) Hoag Hospital (HH); (B) Providence St. Joseph Hospital of Orange (PSJH). Seasonally adjusted levofloxacin (LVX) DOT/1000 PD by month and year: (C) HH; (D) PSJH. LVX DOT/1000 PD with trend lines are depicted in (E) and (F) for HH and PSJH, respectively.

Figure 2.

Correlation analysis of levofloxacin (LVX) and ceftriaxone (CRO) days of therapy (DOT)/1000 patient-days (PD) by months, 3 months, and 6 months at (A) Hoag Hospital (HH); (B) Providence St. Joseph Hospital of Orange (PSJH).

Figure 3.

Correlation analysis of Pseudomonas aeruginosa (PSA) levofloxacin (LVX) nonsusceptibility (non-S) and LVX days of therapy (DOT)/1000 patient-days (PD) data on a 3-month basis for (A) Hoag Hospital (HH) and (B) Providence St. Joseph Hospital of Orange (PSJH) and on a 6-months basis for (C) HH and (D) PSJH.