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James J. Rahal, MD; Carl Urban, PhD; David Horn, MD; Katherine Freeman, DrPH; Sorana Segal-Maurer, MD; James Maurer, MD; Noriel Mariano, BS; Sheila Marks, RN; Janice M. Burns, RN; Dana Dominick, RPh, MS; Mimi Lim, RN, MPA

JAMA. 1998;280:1233-1237.

Context.— Resistance to most or all cephalosporin antibiotics in Klebsiella species has developed in many European and North American hospitals during the past 2 decades.

Objective.— To determine if restriction of use of the cephalosporin class of antibiotics would reduce the incidence of patient infection or colonization by cephalosporin-resistant Klebsiella.

Design.— A before-after comparative 2-year trial.

Setting.— A 500-bed, university-affiliated community hospital in Queens, NY.

Patients.— All adult medical and surgical hospital inpatients.

Intervention.— A new antibiotic guideline excluded the use of cephalosporins except for pediatric infection, single-dose surgical prophylaxis, acute bacterial meningitis, spontaneous bacterial peritonitis, and outpatient gonococcal infection. All other cephalosporin use required prior approval by the infectious disease section.

Main Outcome Measure.— Incidence of patient infection or colonization by ceftazidime-resistant Klebsiella during 1995 (control period) compared with 1996 (intervention period).

Results.— An 80.1% reduction in hospital-wide cephalosporin use occurred in 1996 compared with 1995. This was accompanied by a 44.0% reduction in the incidence of ceftazidime-resistant Klebsiella infection and colonization throughout the medical center (P<.01), a 70.9% reduction within all intensive care units (P<.001), and an 87.5% reduction within the surgical intensive care unit (P<.001). A concomitant 68.7% increase in the incidence of imipenem-resistant Pseudomonas aeruginosa occurred throughout the medical center (P<.01). All such isolates except one were susceptible to other antibiotics.

Conclusion.— Extensive cephalosporin class restriction significantly reduced nosocomial, plasmid-mediated, cephalosporin-resistant Klebsiella infection and colonization. This occurred at the price of increased imipenem resistance in P aeruginosa, which remained susceptible to other agents. Thus, an overall reduction in multiply-resistant pathogens was achieved within 1 year.

From the Infectious Disease Section, Department of Medicine (Drs Rahal, Urban, and Segal-Maurer and Mr Mariano), and the Departments of Surgery (Dr Maurer), Nursing (Mss Marks, Burns, and Lim), and Pharmacy (Ms Dominick), New York Hospital Medical Center of Queens and Cornell University Medical College, and the Department of Biostatistics (Dr Freeman), Montefiore Medical Center and Albert Einstein College of Medicine, New York; and Merck & Co Inc, West Point, Pa (Dr Horn).

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