The Effect of Antibiotic-Cycling Strategy on Antibiotic-Resistant Bacterial Infections or Colonization in Intensive Care Units: A Systematic Review and Meta-Analysis

Abstract

Background: Antibiotic-resistant bacteria, especially multidrug-resistant strains, play a key role in impeding critical patients from survival and recovery. The effectiveness of the empiric use of antibiotics in the circling manner in intensive care units (ICUs) has not been analyzed in detail and remains controversial. Therefore, this systematic review and meta-analysis were conducted to evaluate antibiotic-cycling effect on the incidence of antibiotic-resistant bacteria.

Methods: We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science for studies focusing on whether a cycling strategy of empiric use of antibiotics could curb the prevalence of antibiotic-resistant bacteria in ICUs. The major outcomes were risk ratios (RRs) of antibiotic-resistant infections or colonization per 1,000 patient days before and after the implementation of antibiotic cycling. A random-effects model was adopted to estimate results in consideration of clinical heterogeneity among studies. The registration number of the meta-analysis is CRD42018094464.

Results: Twelve studies, involving 2,261 episodes of resistant infections or colonization and 160,129 patient days, were included in the final analysis. Based on the available evidence, the antibiotic-cycling strategy did not reduce the overall incidence of infections or colonization with resistant bacteria (RR = 0.823, 95% CI 0.655-1.035, p = .095). In subgroup analyses, the cycling strategy cut down the incidence of resistant bacteria more significantly than baseline period (p = .028) but showed no difference in comparison with mixing strategy (p = .758).

Linking evidence to action: Although the cycling strategy performed better than relatively free usage of antibiotics in the baseline period on reducing resistant bacteria, the cycling strategy did not show advantage when compared with the mixing strategy in subgroup analyses. In addition, these viewpoints still need more evidence to confirm.

Keywords: antibiotic mixing strategy; antibiotic-cycling; antibiotic-resistant bacteria; intensive care unit; meta-analysis; multidrug-resistant strains; prognosis; systematic review.