Hostname: page-component-6b989bf9dc-lb7rp Total loading time: 0 Render date: 2024-04-13T20:47:43.456Z Has data issue: false hasContentIssue false

Evaluating the Relationship Between Hospital Antibiotic Use and Antibiotic Resistance in Common Nosocomial Pathogens

Published online by Cambridge University Press:  26 October 2017

Annie Wang
Department of Medicine, University of Toronto, Toronto, Ontario, Canada
Nick Daneman
Department of Medicine, University of Toronto, Toronto, Ontario, Canada Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
Charlie Tan
Sunnybrook Research Institute, Sunnybrook Health Sciences Center, University of Toronto, Ontario, Canada
John S. Brownstein
Boston Children’s Hospital, Boston, Massachusetts, United States
Derek R. MacFadden*
Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
Address correspondence to Derek R. MacFadden, MD FRCPC, 200 Elizabeth St 13EN-213, University Health Network, Toronto, Ontario (



The relationship between hospital antibiotic use and antibiotic resistance is poorly understood. We evaluated the association between antibiotic utilization and resistance in academic and community hospitals in Ontario, Canada.


We conducted a multicenter observational ecological study of 37 hospitals in 2014. Hospital antibiotic purchasing data were used as an indicator of antibiotic use, whereas antibiotic resistance data were extracted from hospital indexes of resistance. Multivariate regression was performed, with antibiotic susceptibility as the primary outcome, antibiotic consumption as the main predictor, and additional covariates of interest (ie, hospital type, laboratory standards, and patient days).


With resistance data representing more than 90,000 isolates, we found the increased antibiotic consumption in defined daily doses per 1,000 patient days (DDDs/1,000 PD) was associated with decreased antibiotic susceptibility for Pseudomonas aeruginosa (−0.162% per DDD/1,000 PD; P=.119). However, increased antibiotic consumption predicted increased antibiotic susceptibility significantly for Escherichia coli (0.173% per DDD/1,000 PD; P=.005), Klebsiella spp (0.124% per DDD/1,000 PD; P=.004), Enterobacter spp (0.194% per DDD/1,000 PD; P=.003), and Enterococcus spp (0.309% per DDD/1,000 PD; P=.001), and nonsignificantly for Staphylococcus aureus (0.012% per DDD/1,000 PD; P=.878). Hospital type (P=.797) and laboratory standard (P=.394) did not significantly predict antibiotic susceptibility, while increased hospital patient days generally predicted increased organism susceptibility (0.728% per 10,000 PD; P<.001).


We found that hospital-specific antibiotic usage was generally associated with increased, rather than decreased hospital antibiotic susceptibility. These findings may be explained by community origins for many hospital-diagnosed infections and practitioners choosing agents based on local antibiotic resistance patterns.

Infect Control Hosp Epidemiol 2017;38:1457–1463

Original Articles
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)



1. Chandy, SJ, Naik, GS, Balaji, V, et al. High cost burden and health consequences of antibiotic resistance: the price to pay. J Infect Dev Countries 2014;8:10961102.Google Scholar
2. Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention website. Published April 23, 2013. Accessed February 18, 2017.Google Scholar
3. Boucher, HW, Talbot, GH, Bradley, JS, et al. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis 2009;48:112.Google Scholar
4. Rice, LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: no ESKAPE. J Infect Dis 2008;197:10791081.CrossRefGoogle Scholar
5. Levy, SB, Marshall, B. Antibacterial resistance worldwide: causes, challenges and responses. Nat Med 2004;10:S122S129.CrossRefGoogle ScholarPubMed
6. Kang, CI, Kim, SH, Park, WB, et al. Bloodstream infections caused by antibiotic-resistant gram-negative bacilli: risk factors for mortality and impact of inappropriate initial antimicrobial therapy on outcome. J Antimicrob Agents Chemother 2005;49:760.CrossRefGoogle Scholar
7. Paul, M, Kariv, G, Goldberg, E, et al. Importance of appropriate empirical antibiotic therapy for methicillin-resistant Staphylococcus aureus bacteraemia. J Antimicrob Chemother 2010;65:26582665.CrossRefGoogle ScholarPubMed
8. Kaki, R, Elligsen, M, Walker, S, et al. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Agents Chemother 2011;66:12231230.CrossRefGoogle ScholarPubMed
9. Fridkin, S, Baggs, J, Fagon, R, et al. Vitals signs: improving antibiotic use among hospitalized patients. Morb Mortal Wkly Rep 2014;63:194200.Google Scholar
10. Hindler, JF, Stelling, J. Analysis and presentation of cumulative antibiograms: a new consensus guideline from the Clinical and Laboratory Standards Institute. Clin Infect Dis 2007;44:867873.Google Scholar
11. MacFadden, DR, Fisman, D, Andre, J, et al. A platform for monitoring regional antimicrobial resistance, using online data sources: ResistanceOpen. J Infect Dis 2016;214:S393S398.Google Scholar
12. Tan, C, Ritchie, M, Alldred, J, et al. Validating hospital antibiotic purchasing data as a metric of inpatient antibiotic use. J Antimicrob Chemother 2016;71:547553.CrossRefGoogle ScholarPubMed
13. Reabstraction study of the ontario case costing facilities: for fiscal years 2002/2003 and 2003/2004. Canadian Health Information Management Association website. Published November 2005. Accessed February 18, 2017.Google Scholar
14. Guidelines for ATC classification and DDD assignment 2013. WHO Collaborating Centre for Drug Statistics Methodology website. Published January 2013. Accessed February 18, 2017.Google Scholar
15. McDougall, DA, Morton, AP, Playford, EG. Association of ertapenem and antipseudomonal carbapenem usage and carbapenem resistance in Pseudomonas aeruginosa among 12 hospitals in Queensland, Australia. J Antimicrob Chemother 2013;68:457460.Google Scholar
16. Miliani, K, L’Hériteau, F, Lacavé, L, et al. Imipenem and ciprofloxacin consumption as factors associated with high incidence rates of resistant Pseudomonas aeruginosa in hospitals in northern France. J Hosp Infect 2011;77:343347.CrossRefGoogle ScholarPubMed
17. Lesho, EP, Clifford, RJ, Chukwuma, U, et al. Carbapenem-resistant Enterobacteriaceae and the correlation between carbapenem and fluoroquinolone usage and resistance in the US military health system. Diagn Microbiol Infect Dis 2015;81:119125.Google Scholar
18. Batard, E, Ollivier, F, Boutoille, D, et al. Relationship between hospital antibiotic use and quinolone resistance in Escherichia coli . Int J Infect Dis 2013;17:e254e258.CrossRefGoogle ScholarPubMed
19. Cuevas, O, Oteo, J, Lázaro, E, et al. Significant ecological impact on the progression of fluoroquinolone resistance in Escherichia coli with increased community use of moxifloxacin, levofloxacin and amoxicillin/clavulanic acid. J Antimicrob Chemother 2011;66:664669.Google Scholar
20. MacDougall, C, Powell, JP, Johnson, CK, et al. Hospital and community fluoroquinolone use and resistance in Staphylococcus aureus and Escherichia coli in 17 US hospitals. Clin Infect Dis 2005;41:435440.Google Scholar
21. Canadian antimicrobial resistance surveillance system report, 2016. Public Health Agency of Canada website. Published September 12, 2016. Accessed March 2, 2017.Google Scholar