In silico and in vitro evaluation of extract derived from Dunaliella salina, a halotolerant microalga for its antifungal and antibacterial activity

In the present study little explored halotolerant wall-less green alga Dunaliella salina was found to be a potent source of antibacterial and antifungal biomolecules. Both the target pathogens, bacteria (Escherischia coli, Klebsiella pneumoniae, and Acinetobacter baumannii) and fungi (Candida albicans, C. tropicalis, and Cryptococus sp.) were WHO prioritized. The bioassay guided approach led us to evaluate antibacterial and antifungal lead molecule(s) from an array of compounds using spectroscopic and in silico studies. The methanol derived crude extract was purified via thin layer chromatography (TLC) using solvent system methanol: chloroform (1:19). Maximum antimicrobial activity was observed in fractions D5, D6 and D7, the components of which were then recognized using high resolution-liquid chromatography/mass spectroscopy (Orbitrap) (HR-LC/MS). The screened compounds were then docked with target enzymes sterol-14-alpha demethylase and OmpF porin protein. The energy scores revealed that amongst all, lariciresinol-4-O-glucoside showed better binding affinity, in silico, using the Schrödinger Maestro 2018-1 platform. The 3-dimensional crystal structures of both the proteins were retrieved from the protein data bank (PDB), and showed binding energies of -14.35 kcal/mol, and -11.0 kcal/mol against respective drug targets. The molecular dynamics (MD) simulations were performed for 100 ns, using Desmond package, Schrödinger to evaluate the conformational stability and alteration of protein-ligand complexes during the simulation. Thus, our findings confirmed that lariciresinol-4-O-glucoside, a lignan derivative and known strong antioxidant, may be used as an important "lead" molecule to be developed as antibacterial and antifungal drugs in the future.Communicated by Ramaswamy H. Sarma.

Microbial Resistance to Antibiotics and Effective Antibiotherapy

Currently, the efficacy of antibiotics is severely affected by the emergence of the antimicrobial resistance phenomenon, leading to increased morbidity and mortality worldwide. Multidrug-resistant pathogens are found not only in hospital settings, but also in the community, and are considered one of the biggest public health concerns. The main mechanisms by which bacteria develop resistance to antibiotics include changes in the drug target, prevention of entering the cell, elimination through efflux pumps or inactivation of drugs. A better understanding and prediction of resistance patterns of a pathogen will lead to a better selection of active antibiotics for the treatment of multidrug-resistant infections.

Variation in antibiotic use across intensive care units (ICU): A population-based cohort study in Ontario, Canada

OBJECTIVES

Antibiotics are commonly used in intensive care units (ICUs), yet differences in antibiotic use across ICUs are unknown. Herein, we studied antibiotic use across ICUs and examined factors that contributed to variation.

METHODS

We conducted a retrospective cohort study using data from Ontario's Critical Care Information System (CCIS), which included 201 adult ICUs and 2,013,397 patient days from January 2012 to June 2016. Antibiotic use was measured in days of therapy (DOT) per 1,000 patient days. ICU factors included ability to provide ventilator support (level 3) or not (level 2), ICU type (medical-surgical or other), and academic status. Patient factors included severity of illness using multiple-organ dysfunction score (MODS), ventilatory support, and central venous catheter (CVC) use. We analyzed the effect of these factors on variation in antibiotic use.

RESULTS

Overall, 269,351 patients (56%) received antibiotics during their ICU stay. The mean antibiotic use was 624 (range 3-1460) DOT per 1,000 patient days. Antibiotic use was significantly higher in medical-surgical ICUs compared to other ICUs (697 vs 410 DOT per 1,000 patient days; P < .0001) and in level 3 ICUs compared to level 2 ICUs (751 vs 513 DOT per 1,000 patient days; P < .0001). Higher antibiotic use was associated with higher severity of illness and intensity of treatment. ICU and patient factors explained 47% of the variation in antibiotic use across ICUs.

CONCLUSIONS

Antibiotic use varies widely across ICUs, which is partially associated with ICUs and patient characteristics. These differences highlight the importance of antimicrobial stewardship to ensure appropriate use of antibiotics in ICU patients.

An overview of the antimicrobial resistance mechanisms of bacteria

Resistance to antimicrobial agents has become a major source of morbidity and mortality worldwide. When antibiotics were first introduced in the 1900's, it was thought that we had won the war against microorganisms. It was soon discovered however, that the microorganisms were capable of developing resistance to any of the drugs that were used. Apparently most pathogenic microorganisms have the capability of developing resistance to at least some antimicrobial agents. The main mechanisms of resistance are: limiting uptake of a drug, modification of a drug target, inactivation of a drug, and active efflux of a drug. These mechanisms may be native to the microorganisms, or acquired from other microorganisms. Understanding more about these mechanisms should hopefully lead to better treatment options for infective diseases, and development of antimicrobial drugs that can withstand the microorganisms attempts to become resistant.

Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review

INTRODUCTION

In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation.

METHODS

We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment.

RESULTS

Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS.

CONCLUSIONS

A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS.

Antibiotic Cycling and Antibiotic Mixing: Which One Best Mitigates Antibiotic Resistance?

Can we exploit our burgeoning understanding of molecular evolution to slow the progress of drug resistance? One role of an infection clinician is exactly that: to foresee trajectories to resistance during antibiotic treatment and to hinder that evolutionary course. But can this be done at a hospital-wide scale? Clinicians and theoreticians tried to when they proposed two conflicting behavioral strategies that are expected to curb resistance evolution in the clinic, these are known as “antibiotic cycling” and “antibiotic mixing.” However, the accumulated data from clinical trials, now approaching 4 million patient days of treatment, is too variable for cycling or mixing to be deemed successful. The former implements the restriction and prioritization of different antibiotics at different times in hospitals in a manner said to “cycle” between them. In antibiotic mixing, appropriate antibiotics are allocated to patients but randomly. Mixing results in no correlation, in time or across patients, in the drugs used for treatment which is why theorists saw this as an optimal behavioral strategy. So while cycling and mixing were proposed as ways of controlling evolution, we show there is good reason why clinical datasets cannot choose between them: by re-examining the theoretical literature we show prior support for the theoretical optimality of mixing was misplaced. Our analysis is consistent with a pattern emerging in data: neither cycling or mixing is a priori better than the other at mitigating selection for antibiotic resistance in the clinic.

Key words: antibiotic cycling, antibiotic mixing, optimal control, stochastic models.

Systematic review of antibiotic consumption in acute care hospitals

Antibiotic consumption is an easily quantifiable performance measure in hospitals and might be used for monitoring. We conducted a review of published studies and online surveillance reports reporting on antibiotic consumption in acute care hospitals between the years 1997 and 2013. A pooled estimate of antibiotic consumption was calculated using a random effects meta-analysis of rates with 95% confidence intervals. Heterogeneity was assessed through subgroup analysis and metaregression. Eighty studies, comprising data from 3130 hospitals, met the inclusion criteria. The pooled rate of hospital-wide consumption was 586 (95% confidence interval 540 to 632) defined daily doses (DDD)/1000 hospital days (HD) for all antibacterials. However, consumption rates were highly heterogeneous. Antibacterial consumption was highest in intensive care units, at 1563 DDD/1000 HD (95% confidence interval 1472 to 1653). Hospital-wide antibacterial consumption was higher in Western Europe and in medium-sized, private and university-affiliated hospitals. The methods of data collection were significantly associated with consumption rates, including data sources, dispensing vs. purchase vs. usage data, counting admission and discharge days and inclusion of low-consumption departments. Heterogeneity remained in all subgroup analyses. Major heterogeneity currently precludes defining acceptable antibiotic consumption ranges in acute care hospitals. Guidelines on antibiotic consumption reporting that will account for case mix and a minimal set of hospital characteristics recommending standardized methods for monitoring and reporting are needed.

Evaluation of regional antibiograms to monitor antimicrobial resistance in Hampton Roads, Virginia

We studied recent antibiograms (2010 to 2011) from 12 hospitals in the Hampton Roads area, Virginia, that refer patients to a tertiary-care facility affiliated with Eastern Virginia Medical School. The data was compiled into a regional antibiogram, and sensitivity rates of common isolates from the tertiary-care facility (central) were compared to those of referring hospitals grouped by locale. Staphylococcus aureus was the most common Gram- positive and E. coli the most common Gram- negative organism grown from clinical samples in the area. Overall 53% of S.aureus isolates were resistant to oxacillin. There was a broad scatter of MIC (minimum inhibitory concentration) for vancomycin within the susceptibility range, and MIC of 4 μg/mL was reported in 2012. Penicillin resistance was seen in 50% and erythromycin resistance in 45% of Streptococcus pneumoniae. Vancomycin resistance was seen in 75% of Enterococcus faecium and 2% of Enterococcus faecalis respectively. Acinetobacter baumannii was the most resistant Gram negative organism in the data compiled. Among the Escherichia coli, 26%, 44% and 52%were resistant to Trimethoprim/Sulfamethoxazole ( SXT) ampicillin- sulbactam and ampicillin respectively. We found significant differences in methodology, interpretation and antibiotic panels used by area laboratories. Based on these findings, we are now prospectively following resistance patterns in the tertiary-care facility, sharing data, and creating a consistent approach to antimicrobial susceptibility testing in the region.

Absence of Association between Use of Ertapenem and Change in Antipseudomonal Carbapenem Susceptibility Rates in 25 Hospitals

Objective.

Ertapenem exposure has been reported to select for cross-resistance to other carbapenems in Pseudomonas aeruginosa in vitro. Single-center investigations report conflicting results. We evaluated ertapenem use and antipseudomonal carbapenem susceptibility for 6 years spanning the time of ertapenem adoption at each of 25 US hospitals.

Design.

Retrospective primary and secondary data analysis.

Methods.

Use density ratios for imipenem and meropenem (collectively, “other carbapenems”) and ertapenem were derived from data in a commercial database on the total number of grams used in the 3 years before and the 3 years after adoption of ertapenem at each hospital. A general linear model using repeated measures analysis of variance was used to explore associations between the 6-year change in antipseudomonal carbapenem susceptibility rates (determined from hospital antibiograms) and ertapenem use in each year, while controlling for other carbapenem use.

Results.

Ertapenem use increased once adopted. With regard to the postadoption period, the median use density ratio for year 4 was 4.1 (interquartile range [IQR], 1.7-5.2), for year 5 was 6.0 (IQR, 2.7-8.5), and for year 6 was 6.5 (IQR, 4.0-11.6). The median use density ratio for other carbapenem use for year 1 was 8.7 (IQR, 5.7-13.5), and by year 6 it had increased to 19.3 (IQR, 9.6-26.2). Change in mean antipseudomonal carbapenem susceptibility across time (85% in year 1 to 82% in year 6) was not significant (P = .22). Change in 6-year antipseudomonal carbapenem susceptibility was not associated with ertapenem use in any year while controlling for other carbapenem use (P &gt; .20 for all years of ertapenem use).

Conclusion.

Although significant change in P. aeruginosa susceptibility to antipseudomonal carbapenems was not detected during this multicenter study, which to our knowledge is the most extensive assessment to date of this important drug use-susceptibility relationship, continued evaluation of the relationship is prudent.

Implementing a strategy for monitoring inpatient antimicrobial use among hospitals in the United States

The Centers for Disease Control and Prevention is pursuing 3 distinct, complementary efforts focused on providing data for action, including facility-level use metrics for benchmarking across comparable patient care settings, national estimates of usage patterns using sentinel surveillance sites, and limited assessments using proprietary data.

Impact of antibiotic use on carbapenem resistance in Pseudomonas aeruginosa: is there a role for antibiotic diversity?

In this study, we aimed to evaluate the relationship between the rates of resistance of Pseudomonas aeruginosa to carbapenems and the levels and diversity of antibiotic consumption. Data were retrospectively collected from 20 acute care hospitals across 3 regions of Switzerland between 2006 and 2010. The main outcome of the present study was the rate of resistance to carbapenems among P. aeruginosa. Putative predictors included the total antibiotic consumption and carbapenem consumption in defined daily doses per 100 bed days, the proportion of very broad-spectrum antibiotics used, and the Peterson index. The present study confirmed a correlation between carbapenem use and carbapenem resistance rates at the hospital and regional levels. The impact of diversifying the range of antibiotics used against P. aeruginosa resistance was suggested by (i) a positive correlation in multivariate analysis between the above-mentioned resistance and the proportion of consumed antibiotics having a very broad spectrum of activity (coefficient = 1.77; 95% confidence interval, 0.58 to 2.96; P < 0.01) and (ii) a negative correlation between the resistance and diversity of antibiotic use as measured by the Peterson homogeneity index (coefficient = -0.52; P < 0.05). We conclude that promoting heterogeneity plus parsimony in the use of antibiotics appears to be a valuable strategy for minimizing the spread of carbapenem resistance in P. aeruginosa in hospitals.

Surveillance of antibiotic consumption using the "focus of infection" approach in 2 hospitals in Ujjain, India

Antibiotic surveillance initiatives are limited in resource-constrained settings. In the present study, a quantitative comparison of antibiotic use rates for suspected infections in 2 hospitals in India was performed using the “focus of infection” approach to identify targets for quality improvement in antibiotic prescription patterns in hospitalized patients.

Functional assignment of YvgO, a novel set of purified and chemically characterized proteinaceous antifungal variants produced by Bacillus thuringiensis SF361

This study reports a novel class of antifungal protein derived from bacterial origin. Bacillus thuringiensis SF361, the strain also responsible for producing the novel bacteriocin thurincin H, exhibits broad antifungal activity against select members of several fungal genera, including Aspergillus, Byssochlamys, and Penicillium, as well as the pathogenic yeast Candida albicans. Optimal antifungal production and secretion were observed after-log phase growth when incubated at 37°C in a carbohydrate-free growth medium. High-performance liquid chromatography purification was performed after pH-selective ammonium sulfate precipitation and size-exclusion chromatography. Intact mass analysis and peptide mass fingerprinting identified the 13,484-Da protein to be a mass homolog to the YvgO protein construct sequenced from Bacillus cereus AH 1134. Further analysis via amino-terminal sequencing also revealed the existence of four distinct yet equally efficacious YvgO variants differing only within the first four N-terminal residues. YvgO was found to be remarkably stable, maintaining its antifungal activity under a wide pH and temperature range. When assayed against the toxigenic species Byssochlamys fulva H25, the selected primary filamentous fungal indicator, the MIC was estimated to be 1.5 ppm. Candida albicans 3153 was more resistant, exhibiting MICs between 25 and 800 ppm, depending on growth conditions. YvgO is unique among antifungals, showing no known sequential or functional homology to the typical classes of antifungal proteins, including common membrane-acting agents such as cellulases and glucanases. Due to its activity against an array of pathogenic and spoilage fungi, the potentials for clinical, agricultural, and food-processing applications are encouraging.

Impact of antibiotic exposure patterns on selection of community-associated methicillin-resistant Staphylococcus aureus in hospital settings

Community-associated methicillin-resistant S. aureus (CA-MRSA) is increasingly common in hospitals, with potentially serious consequences. The aim of this study was to assess the impact of antibiotic prescription patterns on the selection of CA-MRSA within hospitals, in a context of competition with other circulating staphylococcal strains, including methicillin-sensitive (MSSA) and hospital-associated methicillin-resistant (HA-MRSA) strains. We developed a computerized agent-based model of S. aureus transmission in a hospital ward in which CA-MRSA, MSSA, and HA-MRSA strains may cocirculate. We investigated a wide range of antibiotic prescription patterns in both intensive care units (ICUs) and general wards, and we studied how differences in antibiotic exposure may explain observed variations in the success of CA-MRSA invasion in the hospitals of several European countries and of the United States. Model predictions underlined the influence of antibiotic prescription patterns on CA-MRSA spread in hospitals, especially in the ICU, where the endemic prevalence of CA-MRSA carriage can range from 3% to 20%, depending on the simulated prescription pattern. Large antibiotic exposure with drugs effective against MSSA but not MRSA was found to promote invasion by CA-MRSA. We also found that, should CA-MRSA acquire fluoroquinolone resistance, a major increase in CA-MRSA prevalence could ensue in hospitals worldwide. Controlling the spread of highly community-prevalent CA-MRSA within hospitals is a challenge. This study demonstrates that antibiotic exposure strategies could participate in this control. This is all the more important in wards such as ICUs, which may play the role of incubators, promoting CA-MRSA selection in hospitals.

Longitudinal study of antimicrobial-resistant commensal Escherichia coli in the faeces of horses in an equine hospital

The increasing prevalence of antimicrobial resistance in bacteria represents a considerable problem for human and veterinary medicine, causing complications in the treatment of infections. Resistance in Escherichia coli from horses has been documented in commensal and pathogenic strains, but little information exists regarding the prevalence of such bacteria in hospitalised horses or associated risk factors. A longitudinal cohort study was conducted of 103 horses admitted to a referral equine hospital for more than 48 h, with faecal samples collected on hospital admission and subsequently every two days until discharge. Horses undergoing radioactive gamma scintigraphic examination, un-weaned foals and mares with un-weaned foals were excluded. Data were collected from enrolled animals, including antimicrobial treatment history and hospitalisation details. Samples were cultured for resistant E. coli; isolates had their antimicrobial resistance profile determined. High sample prevalence for resistant E. coli was identified for all antimicrobials examined except co-amoxiclav. The prevalence of resistance was consistently lower at admission, rising to a peak 4 days post-admission. Risk factors were analysed using multilevel, multivariable modelling, which identified significant clustering of resistance outcomes within horses. For all outcomes except trimethoprim resistance, the day the sample was obtained was significant, with increased risk of resistance for samples taken on day 2 or later. Antimicrobial treatment in the previous seven days and increased total daily dosages of cotrimoxazole prescribed in the hospital in the previous 24-48 h were associated with increased risk. Location within the hospital and admission reason were significant risk factors for some resistance outcomes. High levels of multidrug-resistant E. coli (47.7% of samples) and extended spectrum β-lactamase-producing E. coli (27.3% of samples) were recovered; such bacteria could significantly complicate treatment if they were the cause of infection and may represent a risk to personnel in close contact with hospitalised horses.

Modelling the impact of antibiotic use on antibiotic-resistant Escherichia coli using population-based data from a large hospital and its surrounding community

OBJECTIVES

To determine the temporal relationship between antibiotic use and incidence of antibiotic-resistant Escherichia coli in both the inpatient and outpatient setting of a large urban area.

METHODS

A retrospective observational time-series analysis was performed to evaluate the incidence of non-duplicate clinical isolates of E. coli resistant to ciprofloxacin, trimethoprim/sulfamethoxazole and cefepime from January 2000 through December 2007, combined with a transfer function model of aggregated data on antibiotic use in both settings obtained from the hospital's pharmacy and outpatient billing offices.

RESULTS

Ciprofloxacin resistance increased from 6.0% (2000) to 15.4% (2007; P<0.0001) and cefepime resistance from 0.9% (2002) to 3.2% (2007; P=0.01). Trimethoprim/sulfamethoxazole resistance remained stable (23.7%-25.8%). Total antibiotic use increased in both settings, while fluoroquinolone use increased significantly only among outpatients. A temporal effect between fluoroquinolone resistance in community E. coli isolates and outpatient use of ciprofloxacin (immediate effect and time lag 1 month) and moxifloxacin (time lag 4 months) was observed, explaining 51% of the variance over time. The incidence of cefepime resistance in E. coli was correlated with ciprofloxacin use in the inpatient (lag 1 month) and outpatient (lag 4 months) settings and with the use of ceftriaxone (lag 0 month), piperacillin/tazobactam (3 months) and cefepime (3 months) in the hospital (R2=51%).

CONCLUSIONS

These results support efforts to reduce prescribing of fluoroquinolones for control of resistant E. coli including extended-spectrum β-lactamase producers and show the added value of time-series analysis to better understand the interaction between community and hospital antibiotic prescribing and its spill-over effect on antibiotic resistance.

Variability in antibiotic use at children's hospitals

BACKGROUND

Variation in medical practice has identified opportunities for quality improvement in patient care. The degree of variation in the use of antibiotics in children's hospitals is unknown.

METHODS

We conducted a retrospective cohort study of 556,692 consecutive pediatric inpatient discharges from 40 freestanding children's hospitals between January 1, 2008, and December 31, 2008. We used the Pediatric Health Information System to acquire data on antibiotic use and clinical diagnoses.

RESULTS

Overall, 60% of the children received at least 1 antibiotic agent during their hospitalization, including >90% of patients who had surgery, underwent central venous catheter placement, had prolonged ventilation, or remained in the hospital for >14 days. Even after adjustment for both hospital- and patient-level demographic and clinical characteristics, antibiotic use varied substantially across hospitals, including both the proportion of children exposed to antibiotics (38%-72%) and the number of days children received antibiotics (368-601 antibiotic-days per 1000 patient-days). In general, hospitals that used more antibiotics also used a higher proportion of broad-spectrum antibiotics.

CONCLUSIONS

Children's hospitals vary substantially in their use of antibiotics to a degree unexplained by patient- or hospital-level factors typically associated with the need for antibiotic therapy, which reveals an opportunity to improve the use of these drugs.

Using secondary data sources for pharmacoepidemiology and outcomes research

The increased availability of electronic medical records and administrative health care databases is adding to the popularity of pharmacoepidemiology and outcomes research studies. Despite their availability, practitioners may be reluctant to use these databases because they lack familiarity with database research in general. The basic principles of research are the same regardless of the data source, but there are a few special considerations. When using secondary data sources for research purposes, special care must be taken to select an appropriate source to ensure that relevant information is available to answer the research question at hand. Special attention must also be paid to selecting the appropriate codes to represent the outcomes and exposures of interest; therefore, a general understanding of coding schemes is necessary. Although time may be saved by not prospectively collecting data, the process of manipulating the data for analysis in secondary databases can be complex. Analysis of data from secondary sources may require special procedures to overcome the lack of randomization. By familiarizing themselves with these special issues, practitioners can use secondary sources to conduct studies that make valuable contributions to the improvement of patient care.

Effect of utilization policies for fluoroquinolones: a pilot study in nova scotia hospitals

BACKGROUND

Antimicrobial resistance results in increased morbidity, mortality, and costs to the health care system. Evidence suggests an association between the use of antimicrobials in hospitals and the development of antimicrobial resistance. Fluoroquinolones constitute one group of antimicrobials that are effective against a variety of bacterial infections, yet they may be subject to misuse. Many hospitals in Nova Scotia have implemented policies to improve antimicrobial prescribing, but the impact of these policies on utilization is unknown.

OBJECTIVES

To evaluate the use of fluoroquinolones in Nova Scotia hospitals using the World Health Organization's Anatomical Therapeutic Chemical classification system with defined daily doses (ATC/DDD) and to examine the influence of hospital policies for utilization of fluoroquinolones in community-acquired pneumonia.

METHODS

During the study period (April 1, 1997, to March 31, 2003), fluoroquinolones were administered at 31 of the 37 hospitals in Nova Scotia's 9 district health authorities. Hospital administrative data, hospital characteristics, and pharmaceutical purchasing data related to use of these drugs were aggregated using the ATC/DDD methodology for the fiscal years 1997/1998 to 2002/2003. District pharmacy directors were surveyed to obtain information about district and individual hospital antibiotic policies. Descriptive statistics were calculated, and univariable regression and multilevel analyses were performed.

RESULTS

Mean overall fluoroquinolone use increased over the study period, from 47.2 DDD/1000 bed-days per year in fiscal year 1997/1998 to 163.8 DDD/1000 bed-days per year in fiscal year 2002/2003 (p < 0.001). Multilevel analysis showed that utilization policies aimed at appropriate prescribing did not affect the use of fluoroquinolones.

CONCLUSION

This study revealed that drug purchasing, hospital administrative, and diagnostic data could be combined to compare the utilization of fluoroquinolones among different hospitals and district health authorities. Utilization policies had little effect on the amount, type, or route of fluoroquinolone use.