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Efforts to address emerging resistance to fluoroquinolone antibiotics must consider inappropriate use in the ER

Fluoroquinolone (FQ) antibiotics such as levofloxacin and ciprofloxacin are highly potent, target a broad-spectrum of bacteria, and are tolerated well by most patients. However, increasing FQ use in recent years has resulted in FQ resistance by several types of bacteria, including the bacteria that cause pneumonia. Strategies to limit this emerging FQ resistance should target the frequently inappropriate FQ use in hospital emergency departments (EDs), recommend the authors of a new study. They found that 80 percent of FQ use among ED patients was inappropriate.

The study was conducted by researchers at the University of Pennsylvania Center for Education and Research on Therapeutics, and was supported in part by the Agency for Healthcare Research and Quality's Centers for Education and Research on Therapeutics (CERTs) program cooperative agreement (HS10399). The researchers judged appropriateness of FQ prescribing among 100 ED patients at two hospitals based on existing hospital antibiotic management guidelines.

Of these 100 ED patients, 81 received an FQ for an inappropriate indication. (Inappropriate rate use in hospitalized patients have ranged from 40 percent to 71 percent.) Of these cases, 53 percent were judged inappropriate because another medication was considered first-line treatment, 33 percent because there was no evidence of infection based on the documented evaluation, and 14 percent because of insufficient evaluation (inability to assess the need for antibiotic therapy). Another disturbing finding was that, of the 19 patients who received an FQ for an appropriate indication, only one received both the correct dose and duration of therapy.

Guidelines recommend FQ use in a variety of clinical situations, including pneumonia in certain circumstances, certain types of gastroenteritis, chronic prostatitis, urinary tract infection if the patient is allergic to the first-line therapy, certain HIV-associated infections, and for other indications. While use of many antibiotics, including FQs, for hospitalized patients required approval by the Antimicrobial Management Program in the two hospitals studied, the hospital EDs did not require approval for use of any medication.

More details are in "Fluoroquinolone utilization in the emergency departments of academic medical centers," by Ebbing Lautenbach, M.D., M.P.H., Lori A. Larosa, Pharm.D., Nishaminy Kasbekar, Pharm.D., and others, in the March 10, 2003, Archives of Internal Medicine 163, pp. 601-605.

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