title: Restrictive antibiotic stewardship associated with reduced hospital mortality in gram-negative infection.
abstract: BACKGROUND
  : Antimicrobial stewardship has an important role in the control of Clostridium difficile infection (CDI) and antibiotic resistance. An important component of UK stewardship interventions is the restriction of broad-spectrum beta-lactam antibiotics and promotion of agents associated with a lower risk of CDI such as gentamicin. While the introduction of restrictive antibiotic guidance has been associated with improvements in CDI and antimicrobial resistance, evidence of the effect on outcome following severe infection is lacking.
  
  
  METHODS
  : In 2008, Glasgow hospitals introduced a restrictive antibiotic guideline. A retrospective before/after study assessed outcome following Gram-negative bacteraemia in the 2-year period around implementation.
  
  
  RESULTS
  : Introduction of restrictive antibiotic guidelines was associated with a reduction in utilization of ceftriaxone and co-amoxiclav and an increase in amoxicillin and gentamicin. Approximately 1593 episodes of bacteremia were included in the study. The mortality over 1-year following Gram-negative bacteraemia was lower in the period following guideline implementation (RR 0.852, P  = 0.045). There was no evidence of a difference in secondary outcomes including ITU admission, length of stay, readmission, recurrence of bacteraemia and need for renal replacement therapy. There was a fall in CDI (RR 0.571, P  = 0.014) and a reduction in bacterial resistance to ceftriaxone and co-amoxiclav but no evidence of an increase in gentamicin resistance after guideline implementation.
  
  
  CONCLUSIONS
  : Restrictive antibiotic guidelines were associated with a reduction in CDI and bacterial resistance but no evidence of adverse outcomes following Gram-negative bacteraemia. There was a small reduction in one year mortality.
authors: From the Institute of Infection, Inflammation and Immunity, University of Glasgow, Glasgow 8QQ 12, UK.
authors: N D
authors: ND
authors: Ritchie
authors: From the Institute of Infection, Inflammation and Immunity, University of Glasgow, Glasgow 8QQ 12, UK.
authors: S C
authors: SC
authors: Irvine
authors: Department of Renal Medicine, Queen Elizabeth University Hospital, Glasgow 4TF G51, UK.
authors: A
authors: A
authors: Helps
authors: Infectious Diseases Unit, Queen Elizabeth University Hospital, Glasgow, 4TF G51, UK.
authors: F
authors: F
authors: Robb
authors: Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow G31 2ER, UK.
authors: B L
authors: BL
authors: Jones
authors: Infectious Diseases Unit, Queen Elizabeth University Hospital, Glasgow, 4TF G51, UK.
authors: R A
authors: RA
authors: Seaton
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000188:drug therapy / Q000401:mortality; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000188:drug therapy / Q000453:epidemiology; D024881:Drug Resistance, Bacterial; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000188:drug therapy* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012606:Scotland / Q000453:epidemiology; D018746:Systemic Inflammatory Response Syndrome / Q000188:drug therapy / Q000401:mortality
chemical_list: D000900:Anti-Bacterial Agents