The case for antimicrobial stewardship: Fluoroquinolone edition

Gobo and Wembly Fraggle deliver fluoroquinolones to the wise Trash Heap

Dan posted yesterday about the scary emergence of ceftriaxone-resistant Neisseria gonorrhoeae. I remember back in my Cleveland medical school days that we were the first in the continental US to lose the ability to treat gonoccocal infections with fluoroquinolones.  I distinctly remember the Sanford Guide recommending against quinolones if the patient had traveled to Asia or Cleveland!  I always thought that was funny.  Here is a quote from an EID article: "In the CDC-sponsored Gonococcal Isolate Surveillance Project in the United States, the frequency of strains with intermediate resistance has increased significantly from 1991 to 1994...the increase in strains with intermediate resistance is associated largely, but not exclusively, with the persistence of such strains in Cleveland, Ohio."

Now we have some more news about fluoroquinolones and again it comes from Cleveland.  Nicole Werner and colleagues reviewed six weeks of fluoroquinolones prescriptions at a city-hospital in Cleveland. The study covered 227 courses in 226 patients (why not exclude the single patient treated twice?) and 1,773 total days of therapy. 70 (31%) or the regimens were deemed unnecessary and fully 690 days (39%) were determined to be unnecessary.

Twenty-seven percent of the regimens were associated with adverse effects -  GI adverse effects (14% of regimens), colonization by resistant pathogens (8%), and Clostridium difficile infection (4%).

I know, it is probably too late to save fluoroquinolones from the trash heap of used-up antibiotics, but when will we ever learn?  Do you think it's time that antimicrobial stewardship programs are finally mandated for all hospitals?  I suspect we will probably have to limit antibiotic prescriptions to ID specialists to have much of an effect.  Many of us have wondered why only oncologists can prescribe chemotherapy while every clinician can go about prescribing antibiotics willy-nilly.  Why do we continue to squander a limited public health resource like antibiotics?  It is not like the findings of this new study are all that surprising - I actually thought it might be worse. Yet 40% of fluoroquinolone-days are wasted and 27% of patients get a side-effect with 4% getting C. diff?? Really? That means for every 25 patients treated, one gets C. diff. How bad does it have to get before we change our system of antibiotic prescriptions? EOR

Werner NL et al BMC Infectious Diseases 2011