Measuring and Interpreting Associations between Antibiotic Use and Penicillin Resistance in Streptococcus pneumoniae

Transcription

1 MAJOR ARTICLE Measuring and Interpreting Associations between Antibiotic Use and Penicillin Resistance in Streptococcus pneumoniae Marc Lipsitch Department of Epidemiology, Harvard School of Public Health, Boston Studies of the relationship between antibiotic use and resistance in pneumococci have produced conflicting results, reflecting differences in study design, setting, and measures of association used. Mathematical models of pneumococcal transmission dynamics provide a framework for interpreting and reconciling these studies. The model predicts, and the review of published studies confirms, that treatment often has little effect in increasing an individual s absolute risk of carrying/being infected by penicillin-resistant Streptococcus pneumoniae (PRSP). However, treatment substantially increases a patient s risk of carriage of/infection by PRSP relative to that of penicillin-susceptible S. pneumoniae (PSSP). The appropriate measure of association depends on the question of interest. Antibiotic use can substantially increase the prevalence of risk in the community as a whole, even when there is a small or nonexistent effect of treatment on the absolute risk that a treated individual will carry a resistant organism. Recommendations for the design and analysis of future studies of antibiotic treatment and pneumococcal resistance are proposed. Resistance of Streptococcus pneumoniae to penicillin and other antimicrobial agents is an increasing problem [1, 2]. Many studies have examined the relationship between antibiotic treatment of a patient (usually with a b-lactam or a cephalosporin) and that patient s risk of carrying, or being infected by, penicillin-resistant S. pneumoniae (PRSP). The results of these studies have varied considerably. This variation reflects differences in study design, time scale, and setting, as well as the measures of association used. This paper proposes a framework for interpreting these studies to draw conclusions about the individual and community-level ef- Received 19 May 2000; revised 9 August 2000; electronically published 23 March Presented in part: 2d International Symposium on Pneumococci and Pneumococcal Diseases, Sun City, South Africa, March 2000 (abstract O74). Reprints or correspondence: Dr. Marc Lipsitch, Dept. of Epidemiology, Harvard School of Public Health, 677 Huntington Ave., Boston, MA Clinical Infectious Diseases 2001; 32: by the Infectious Diseases Society of America. All rights reserved /2001/ $03.00 fects of antimicrobial treatment on penicillin resistance in pneumococci. The design and interpretation of epidemiological studies depend on the public health questions of interest. Studies of the association between use of antimicrobial agents and resistance in the pneumococcus can provide information on 3 important issues. The first issue is the individual effects of treatment on resistance. Does treatment with an antibiotic make the treated patient more likely to be colonized with, or infected by, a resistant organism? How do antibiotics or doses differ in this respect? The second issue is the community-wide effect of treatment on resistance. How does the use of antibiotics by individual patients affect the probability that other members of the community will be colonized with or infected by resistant organisms? How do changes in antibiotic use in the community as a whole affect the level of resistance in the pneumococcal population? The third issue is the informativeness of antibiotic treatment history for the prediction of resistance. If a patient presents with a likely or confirmed pneumococcal infection, what (if 1044 CID 2001:32 (1 April) Lipsitch

2 any) information does the patient s recent history of antibiotic use provide to the physician who is choosing an antibiotic for treatment of the patient s current infection? The first part of this article describes how studies can be designed and interpreted to address each of these questions. The second part of this article describes a simple mathematical model that can be used as a framework for the analysis of the effects of antimicrobial treatment on pneumococcal colonization in observational and randomized studies of individual patients. The model is used to predict the way in which the magnitude of the association between resistance and previous antibiotic treatment will depend on the measure used and on the time interval between antibiotic exposure and measurement of pneumococcal carriage or disease. The third part of this article reviews, within the framework for analysis described, published studies of the association between antibiotic use and penicillin resistance in pneumococci. For the sake of brevity and clarity, the abbreviations PSSP (to denote penicillin-susceptible S. pneumoniae) and PRSP are used throughout the article, although many studies also distinguish between intermediately resistant and highly resistant pneumococci. MEASURING THE RELATIONSHIP BETWEEN ANTIBIOTIC USE AND PENICILLIN RESISTANCE IN PNEUMOCOCCI The association between antibiotic use and penicillin resistance in pneumococci has been measured by use of diverse study designs. Nearly all of these studies compare carriage (or infection) rates among treated versus untreated patients; treatment status may be measured before and after an intervention (e.g., in a randomized comparison of antibiotic regimens), or it may be defined as a history of antibiotic use during a defined time period before sampling (e.g., in observational studies). Such data fit into the categories shown in table 1. These data are usually analyzed in 1 of 2 ways. Some studies test for an association between exposure to the antibiotic(s) and carriage of PRSP, as opposed to noncarriage of PRSP. This association can be measured as an OR, which can be called the simple OR ( OR S ) because it compares carriage of PRSP with noncarriage of PRSP. OR S is defined as OR Sp [R T(NU R U)]/[R U(NT R T)] p [R T(X U S U)]/[R U(X T S T)]. Here, X is the proportion of subjects who are noncarriers of S. pneumoniae, S is the proportion of subjects carrying PSSP, and R is the proportion of subjects carrying PRSP. Subscripts U and T refer to untreated and treated subjects, respectively. The total numbers of treated and untreated hosts are denoted by N T and N U, respectively (see table 1). In other studies, PRSP carriers (or infected persons) are compared with members of a different reference group: PSSP carriers (or people infected with PSSP). This association can be Table 1. Groups of subjects in a study of the association between antibiotic use and colonization with resistant pneumococci. Treatment status Patients not colonized with pneumococci Patients colonized with PSSP PRSP Total Before treatment/ did not receive antibiotics X U S U R U N U After treatment/ received antibiotics X T S T R T N T NOTE. PRSP, penicillin-resistant Streptococcus pneumoniae; PSSP, penicillin-susceptible S. pneumoniae. measured by a different OR, which can be called the conditional OR ( OR C ) because it refers to the odds of having a resistant pneumococcus, conditional on carriage of (or infection with) some pneumococcus. OR C is defined as OR Cp RTS U/RUST. For any antibiotic that is effective in reducing total pneumococcal carriage, we will have XT1 X U; as a result, we expect that, in all cases, OR C should be greater than OR S (i.e., OR C1 OR S). These measures provide different information about the effect of treatment on resistance. OR S measures the direct effect of treatment on a person s risk of colonization or infection with resistant pneumococci. If OR S 1 1, it indicates (subject to the usual caveats in epidemiologic studies) that treatment of a person makes that person more likely to be infected or colonized with resistant organisms. By contrast, OR C is poorly suited to measuring the effect of treatment on an individual s absolute risk for colonization or infection with resistant pneumococci. If antibiotic treatment clears carriage of susceptible pneumococci but has no effect on resistant organisms, then this OR will be elevated, even though a person s risk of carrying resistant organisms is unchanged. Moreover, an antibiotic that clears carriage even of resistant organisms in some patients may reduce the person s risk of carriage of resistant organisms, yet OR C could still exceed 1 if the antibiotic kills susceptible bacteria more efficiently than it kills resistant bacteria. OR C is well suited to address the other 2 issues described in the introduction to this article: the community-wide effects of treatment and the informativeness of treatment history for the choice of antibiotics. To decide what antibiotic to prescribe, a physician would need to answer the following question: given that this patient has an infection (which is definitely or probably pneumococcal) and given that this patient has recently been treated with a particular antibiotic, is the infectious microorganism more likely to be resistant to that antibiotic than the same infection would be in someone who has not been treated recently? This is exactly the question that OR C answers. Penicillin-Resistant Pneumococci CID 2001:32 (1 April) 1045

3 With regard to community-level effects, the reason for the importance of OR C is more subtle. One important way in which antibiotic use promotes antibiotic resistance at the community level is by clearing carriage of drug-susceptible organisms. In this way, it produces indirect effects on the population as a whole by reducing the population s exposure to drug-susceptible organisms; this effect is similar to the herd immunity effects of vaccination [3]. In the case of antibiotics, however, this population effect also promotes the spread of resistant organisms, because different pneumococcal populations compete to colonize hosts [4, 5]. Therefore, any action (such as treatment) that reduces the successful transmission of susceptible organisms will promote the transmission of resistant ones at the population level. In terms of mathematical transmission models, treatment reduces the basic reproductive rate ( R 0 ) [3] of susceptible organisms. Specifically, treatment of individuals who carry susceptible organisms reduces their infectiousness, their duration of carriage, or both. This results in an increased prevalence of resistant organisms [6]. The OR C reflects this process because it measures the reduction in carriage of susceptible pneumococci in a treated person as well as the increased carriage of resistant organisms. Although discussion on this topic has been framed in terms of univariate measures (ORs), the principles apply equally well to multivariate measures, such as multiple logistic regressions. TREATMENT AND RESISTANCE: A SIMPLE MODEL OF THE DYNAMICS OF PNEUMOCOCCAL CARRIAGE In this section, a mathematical model of the dynamics of pneumococcal carriage among the subjects of a particular intervention study is used to predict how these measures of the association between antibiotic use and resistance will change during the interval from the time when a patient is treated to the time when his or her pneumococcal carriage is sampled. The purpose is to complete the framework for analysis of existing studies and to suggest principles for the design of future studies. Structure of the model. The dynamics of colonization with susceptible and resistant pneumococci can be captured in a simple mathematical model, as illustrated in figure 1. (See figure 2 in the study by Feikin et al. [7] for illustration of a similar model.) For reasons of simplicity, the model shown in figure 1 is used to describe an intervention study in which subjects are treated with a particular antibiotic regimen, and their carriage rates before and after treatment are compared by use of the aforementioned ORs. With suitable modifications, this model could be used for cross-sectional or other observational study designs. The model shown in figure 1 presents the colonization-loss dynamics among a group of study subjects that is relatively small in number compared with the size of the whole community. This model is in contrast to most transmission-dynamic models of antibiotic treatment [6, 8], which consider the dynamics in the whole community. Consider a closed population before the trial starts. This population contains individuals who have not yet received treatment. These individuals are classified into 3 categories that correspond to the titles of columns 2 4 in table 1. The arrows in figure 1 represent transitions between categories. Patients who are not carrying pneumococci (X) are colonized by susceptible and resistant pneumococci at rates of ls and lr, which changes their classification to the S and R categories, respectively. Once colonized, these patients clear colonization with susceptible and resistant pneumococci at rates of ms and mr, respectively, in the absence of treatment. The equations for this system (for both treated and untreated hosts) are: ds p l S X m S S dt dr p l R X m R R dt X p 1 S R. (1) If the source population for the study has reached a steady state, it will have proportions R Up lrm S/(lSmR lrms mrm S) colonized with resistant pneumococci and S U p lm/(l S R SmR lrms mrm S) colonized with susceptible pneu- mococci. These proportions are obtained by solving equation [1] for equilibrium. Treatment may have several effects on the carriage status of patients. When patients with carriage of susceptible bacteria are treated, they will be cleared of carriage and will be reclassified as belonging to the uncolonized X category of patients, with a probability of p SX. Some patients in the S category may already carry a small subpopulation of resistant organisms, so we allow for the possibility that treatment will result in the patient category changing from S to R with a probability of p SR. Finally, some antibiotics will have partial efficacy in clearing the carriage of organisms that are classified as resistant, so we allow for the possibility that treatment will result in a change in the patient category changing from R to X with a probability of p RX. Time (t) is measured from the moment t p 0, when each person is treated. Immediately after treatment, the values of the variables are reset as follows: 1046 CID 2001:32 (1 April) Lipsitch

4 Figure 1. Structure of a simple model for analysis of an antibiotic treatment trial in a population exposed to colonization by both resistant and susceptible pneumococci. Left, Before treatment, susceptible patients (X) are colonized by penicillin-susceptible and penicillin-resistant pneumococci at rates of ls and lr, respectively. Colonization is lost at rates of ms and mr, respectively. These processes are described by equation [1] in the text. Right, Treatment clears carriage of susceptible bacteria with probability p SX, clears carriage of resistant bacteria with probability p RX, and transfers patients from primarily carrying susceptible bacteria to primarily carrying resistant bacteria with probability p SR. These processes are described by equation [2] in the text. At the end of treatment, patients are again exposed to the processes of colonization and loss at their pretreatment rates. X, noncarriers of Streptococcus pneumoniae; S, carriers of penicillin-susceptible pneumococci; R, carriers of penicillin-resistant pneumococci; arrows, transitions between categories. See table 2 for a list of parameter values for this illustrative model. S T( 0) p ( 1 psx psr) SU( 0) R T( 0) p ( 1 prx) RU( 0) psrsu( 0) XT( 0) p X U( 0) psxsu( 0) prxru( 0 ). (2) For simplification, we make the assumption that no further changes occur during treatment; thus, for treatment of duration d, we set (for all t d): S T(t) p S T(0), R T(t) p R T(0), X T(t) p X T(0). After treatment is completed, patients are recolonized at rates ( ls and lr) equal to the rates at which they acquired colonization before treatment, and they also begin to lose colonization at pretreatment rates; therefore, for t 1 d, equation [1] takes effect for treated hosts, with starting conditions given by equation [2]. The values of the parameters for rates of colonization (l) and loss (m) will depend on the population studied, and the probabilities of the various events upon treatment (p) will additionally depend on the antibiotic being used and the susceptibility profile of the strains in the population. For example, if one were considering both a population that had many strains with MICs just slightly greater than the resistance breakpoint and an antibiotic that reached very high effective concentrations, p RX might be relatively high, whereas for an antibiotic that never reached in vivo concentrations that approached the MIC of resistant strains, p RX would be nearly 0. Table 2 shows the parameters used for the purpose of illustration in figure 2. Predictions of the model. Figure 2 shows the modeled dynamics of colonization in the subjects of a trial before and after treatment. Shown are the proportions of the population colonized with susceptible or resistant bacteria at a given interval after treatment (figure 2, top) and the values of the 2 aforementioned ORs as they change over time (figure 2, bottom). In this example, 50% of subjects had carriage of susceptible bacteria before treatment and 20% had carriage of resistant bacteria. Treatment began at day 0 and lasted for 10 days. Treatment resulted in a 20% reduction in carriage of resistant bacteria (from 20% to 16%) and a 90% reduction in carriage of susceptible bacteria (from 50% to 5%). In many settings (including our hypothetical one), ls is greater than lr. This reflects the fact that most of the pneumococci to which people are exposed are susceptible to penicillin. If we return to our hypothetical example and look at how the ORs will change over time, OR C jumps to 8 for patients whose carriage is measured just after treatment, OR C p [(16%)(50%)]/[(20%)(5%)] p 8, and it then declines rapidly from that peak as treated patients are recolonized. By contrast, OR S declines to slightly less than 1 immediately after treatment, OR S p [(16%)(80%)]/[(20%)(84%)]p The decline reflects the reduction in carriage of resistant organisms that is caused by treatment. As time passes, OR S creeps upward, as the temporary glut of uncolonized patients created by treatment experiences recolonization. OR S reaches a peak value of 1.18 approximately 100 days after treatment. As time goes on, the population returns to its pretreatment equilibrium, which returns both ORs to 1. These results are typical of those that are predicted by the Table 2. Parameter values for the illustrative model shown in figure 1. Parameter l R l S m R m S Value 1.8/y 4.5/y 2.7/y 2.7/y p RX 0.2 p SR 0 p SX 0.9 NOTE. lr, rate of colonization by resistant pneumococci; ls, rate of colonization by susceptible pneumococci; m R, rate of clear- ance of resistant pneumococci; m S, rate of clearance of susceptible pneumococci; p RX, probability that, upon treatment, a carrier of resistant pneumococci is cleared of carriage; p SR, probability that, upon treatment, a carrier of susceptible pneumococci becomes a carrier of resistant pneumococci; p SX, probability that, upon treat- ment, a carrier of susceptible pneumococci is cleared of carriage. Penicillin-Resistant Pneumococci CID 2001:32 (1 April) 1047

5 Figure 2. Time course of a hypothetical study of the effect of an antibiotic treatment on carriage. Top, Proportions of the subjects in the trial who had carriage of resistant (thick line) or susceptible (thin line) pneumococci. Bottom, The 2 measures of association between treatment and resistance simple OR (thick line) and conditional OR (thin line) at various times after treatment. Parameters are the same as those shown in table 2. model for reasonable values of the parameters. The model makes the following general predictions: 1. OR C will usually reach its highest level immediately after treatment and will decline as the interval between treatment and sampling gets longer. 2. OR S may be 11, 1, or!1 just after treatment. If psr is not too large, OR S is expected to increase over time, reaching its maximum at days after treatment and then declining back toward 1. OR S 1 1 reflects an absolute increase in the carriage of resistant bacteria as a result of treatment. This will occur if more people move from category S to category R as a result of the outgrowth of a resistant subpopulation, in comparison with the number of those who move from category R to category X as a result of treatment-induced clearance of resistant carriage. If the opposite is true, we will observe OR S! OR S is likely to be elevated when a study is performed in a population that has had a sudden increase in exposure to resistant organisms, such as in an outbreak of a resistant strain. The model assumed that the subjects exposure to resistant and susceptible organisms remained constant over time. In the context of an outbreak of resistant organisms (or any sudden increase in exposure to colonization of resistant organisms), patients who are treated may be more likely to become colonized with resistant organisms of the outbreak strain than they would have been before they were treated. As a result, treatment during an outbreak may be an important risk factor for carriage of resistant organisms, even when measured by OR S, although it would not be if the same study were done in the same population at a different time (i.e., if it were not done during an outbreak). Study design and analysis. The aforementioned considerations have several implications for study design. First, studies will virtually always have a greater power to detect an effect of treatment on resistance if they measure OR C than if they measure OR S, simply because the size of the effect is larger for OR C. Second, in any given trial, the OR C will be largest (and, therefore, easiest to detect) if a short time span between treatment and sampling is used; therefore, a greater effect is expected if antibiotic use during the previous month is tested as a risk factor for PRSP disease (vs. PSSP disease), rather than if use within the previous 2 months is considered. Third, OR S may be close to 1 at any given time, and the optimal sampling time for OR S will be variable. If one is interested in determining the extent to which treatment clears carriage of resistant organisms, then patients should be sampled as soon as possible after treatment. Carriage of resistant organisms after treatment may peak at any time from weeks to a few months after treatment, as patients who have had their susceptible organisms cleared by treatment are recolonized (some of them, by resistant organisms; figure 2). These conclusions may change if the outgrowth of preexisting resistant subpopulations is a major factor, as it appears to be in some studies of other antibiotic and resistance associations in pneumococci (see the Discussion section) [7, 9, 10]. Although investigators may differ in their primary interest when undertaking any given study, many studies have the potential to provide additional information on several questions in addition to their primary end points. For most observational studies, data of the sort given in table 1, together with relevant univariate and multivariate analyses of both OR C and OR S, will provide maximal information and will allow the investigators to separate out the mechanistic effects of treatment on resistance; these effects include reduction of PSSP carriage, possible reduction of PRSP carriage, outgrowth of resistant subpopulations in treated hosts, and in the longer term, possible increased susceptibility to PSSP carriage. In many intervention studies and in some longitudinal ones, 1048 CID 2001:32 (1 April) Lipsitch

6 a more informative option is available: stratification of the antibiotic effect according to the carriage status of the patient before treatment (as shown in table 3) [7, 11]. When data are presented in this form, it becomes natural to describe the effect of treatment in each of the category transitions shown in figure 1: clearance of PSSP carriage, which changes the patient category from S to X; clearance of PRSP carriage, which changes the patient category from R to X; and clearing PSSP carriage but permitting the outgrowth of a PRSP strain (which may have been there originally in large numbers, or which may be acquired during or just after treatment), which changes the patient category from S to R. From a statistical perspective, such an analysis has the benefit of controlling for some (although not all) of the nonindependence of observations of the same patient before and after treatment, by conditioning on colonization status before treatment. INTERPRETATION OF EXISTING STUDIES Table 4 presents the results of 14 published studies of the association between antibiotic use and infection with penicillinresistant pneumococci; table 5 shows the results of 17 such studies of carriage (one of which includes some invasive disease isolates). A total of 1033 English-language abstracts were obtained by searching MEDLINE records through the end of 1999 for studies of humans by use of the key words Streptococcus pneumoniae and penicillin, along with the terms resistant or resistance. From these abstracts, we identified 45 possible articles that appeared as if they might meet the criteria of being either (1) prospective treatment studies with data on carriage of PSSP and PRSP before and after treatment, or (2) observational studies in which treatment with an antimicrobial agent or with classes of antimicrobial agents, performed during a defined time period, was examined as a risk factor for carriage of or infection with penicillin-resistant pneumococci. Studies were included only if 1 or both of the aforementioned ORs (or corresponding RRs) were calculated, or if they could be calculated from the data given. Studies of HIV-infected patients or patients with sickle-cell anemia were excluded. Of the 45 studies, 26 were included; of the remaining studies, 1 was unobtainable and 18 did not provide the relevant data. Five additional references were identified through the bibliographies of these and other sources. The methodologies used in these studies were described in various ways, and they have been classified as case-control studies, cross-sectional (or in 1 case, longitudinal) prevalence studies, or before-after (intervention) studies. For the studies that reported relevant ORs, the ORs have been reproduced in tables 4 and 5. For studies that analyzed the data in other ways (or reported only 1 of the 2 ORs), other ORs were calculated whenever possible; calculations that are not reported in the original Table 3. Stratification of patients in a treatment study, according to pneumococcal carriage status before treatment. Pneumococcal carriage status before treatment Pneumococcal carriage status after treatment Uncolonized Colonized with PSSP Colonized with PRSP Total Uncolonized N UU N US N UR X U Colonized With PSSP N UU N US N SR S U With PRSP N RU N RS N RR R U Total X T S T R T N NOTE. PRSP, penicillin-resistant Streptococcus pneumoniae; PSSP, penicillin-susceptible S. pneumoniae. Marginal totals are the entries in table 1. article are shown in parentheses. Statistical significance (which is indicated in the footnotes of the tables) reflects calculations reported in each original article, when available. In assessing the significance of ORs calculated for the present analysis and 2 not present in the original article, the x test or Fisher s exact test was used (EpiInfo 6; CDC). In the studies of pneumococcal disease, only OR C could be calculated. Nine of the 14 studies, including most of those that had larger sample sizes, reported a statistically significantly greater risk of PRSP disease than of PSSP disease among patients who had received antibiotics or some class of antibiotics. This is in accord with my prediction that OR C generally should be large and relatively easy to detect. Therefore, these studies collectively provide considerable evidence to indicate that, when a patient has a pneumococcal infection, it is more likely to be penicillin resistant if that patient was recently treated with an antibiotic or with a b-lactam in particular. The studies of carriage were more variable in their design and included 4 intervention (before-after) studies and 13 observational studies. In nearly all of the studies for which OR C was available, OR C was significantly greater than 1. In 5 studies, OR C was not significantly greater than 1 at any point in time [11, 27, 31, 33, 34]. Possible explanations include limited power [11, 27, 31] and, in 1 study, the use of cefaclor, which has poor activity against pneumococci in the nasopharynx [11]. In the 2 cases where OR C was calculated for prior antibiotic use over different time periods, it was largest for the shortest time period and then declined, as predicted [35, 36]. The model predicted that OR S would rarely be much bigger than 1, except in the context of an outbreak of a resistant organism. All 3 studies conducted during an outbreak of microorganisms concluded that the treated subjects were at significantly higher absolute risk of carriage of resistant organisms than were untreated subjects ( OR S 1 1) [37 39]. In most of the remaining cases, OR S was not significantly greater than 1. Indeed, in 3 studies all of which were intervention trials in Penicillin-Resistant Pneumococci CID 2001:32 (1 April) 1049

7 Table 4. Studies of the association between antibiotic use and penicillin-nonsusceptible pneumococcal infection. Reference Geographic location of study Study type No. of Risk patients Time a factor Cases b OR C [12] France CC, PB mo b I 1.99 c M [13] El Vallés County, Spain CC, PB mo A I, O 5.9 c (R) or 2.1 c (Int) M [14] Uruguay and Argentina CC, Hosp mo P, Amp I, O 2.9 c U [15] Colorado CC, Hosp mo A I 2.5 U [16] Kentucky CC, OP d d A O 6.68 c U [17] Texas CC, Hosp mo A I 3.5 c U [18] Cádiz, Spain CC, Mult hosp 95 3 mo b I, O 2.8 c U, 2.8 M [19] Topolcany, Slovakia CC, Hosp 83 CAU A O 14.6 c U [20] Barcelona, Spain CC, Hosp 72 3 mo b 1 5d I 8.3 c U [21] Cleveland CC, Hosp 69 1 mo A I c U [22] Houston CC, DCC, RO 69 1 mo A I 0.9 e U [23] San Antonio CC, Hosp 42 3 mo B B (36) c U, NG f M [24] Oklahoma City CC, Hosp, Mtch 36 2 mo A f I, O NS g U [25] CC, Mult hosp 31 NG A I (1.74) U NOTE. A, antibiotics; Amp, ampicillin; b, b-lactams; B, bacteremia; CC, case-control study; CAU, current antibiotic use (at time of sampling); DCC, day care center; Hosp, hospital; I, invasive disease; Int, intermediately susceptible; Mtch, matched; M, multivariate analysis; Mult hosp, multiple hospitals; NG, not given; O, otitis media; OP, outpatient practices; OR C, conditional OR, as defined in the text; PB, population based; R, resistant; RO, outbreak of a resistant strain; U, univariate analysis. a Time prior to culture during which antibiotic risk factor is measured. b All values are for any nonsusceptible (Int or R) strain, unless noted. c Statistically significant at P!.05. d Using tympanocentesis. e Risk was for multidrug-resistant Streptococcus pneumoniae, not strictly for penicillin-resistant S. pneumoniae. f Significant multivariate effect was reported, but the OR was not. g Data do not allow for calculation of the OR. which patients were sampled at 7 14 days after treatment with amoxicillin-clavulanate treated patients were less likely to carry resistant organisms than were untreated ones ( OR S! 1), and this association reached statistical significance. This suggests that amoxicillin-clavulanate may be particularly effective for clearance of nasopharyngeal carriage of resistant (including intermediately resistant) S. pneumoniae, and it is also consistent with the prediction that OR S may be depressed below 1 just after treatment. There were just 2 studies in which OR S was significantly greater than 1, apart from those performed in the context of resistant outbreaks. In one of these studies, only low doses of antibiotics or treatment of long duration were implicated, and the frequency of colonization was extremely low, probably as a result of the use of oropharyngeal sampling [40]. The other study also involved a small number of children ( n p 48), al- though several samples were obtained from each child [41]. The following conclusions may be drawn from the existing studies: carriage of susceptible organisms, thereby indirectly promoting the transmission of resistant ones [6, 42]. 2. In the setting of an outbreak of a resistant pneumococcus, antibiotic treatment puts a patient at a higher risk for colonization by the resistant strain ( OR S 1 1). This presumably occurs because clearance of the patient s own flora makes new colonization more likely, and the patient will have substantial exposure to the resistant strain. 3. Outside the setting of a resistant outbreak, there is little evidence that treatment makes a patient more susceptible to carrying a resistant strain than an untreated individual patient would be. Indeed, in some circumstances, at least in the short term, treatment can clear a person of colonization with even a resistant strain ; this has been shown in trials only of amoxicillin-clavulanate [33, 34, 43]. Therefore, the possibility that treatment puts a person at greater risk for resistant carriage (or infection), although perhaps suggested by 2 aforementioned studies [40, 41], should not be accepted without further study. 1. Recent antibiotic treatment makes it more likely that a patient who is carrying a pneumococcus has a resistant (rather than a susceptible) organism ( OR C 1 1). This suggests that antibiotic (in particular, b-lactam or cephalosporin) treatment is exerting an important effect at the community level by reducing DISCUSSION Growing concern about antibiotic resistance in general and about penicillin resistance in pneumococci in particular, has led to a growing number of studies searching for modifiable 1050 CID 2001:32 (1 April) Lipsitch

8 Table 5. Studies of the association between antibiotic use and penicillin-nonsusceptible pneumococcal carriage. Reference Geographic location of study Study type No. of patients Time a Risk factor OR C OR S [11] Israel B, PTS d 4 5 d [26] Iceland DCC, P mo b 1 2 b 3 TS 1 2 TS 3 E 1 2 E 3 CU Cef (5.5) (1) 6.75 b M 6 b M 7.2 b M 13.1 b M 8.6 b M 12.2 b M [27] Nebraska DCC, P mo A 2.1 U [28] Yukon-Kuskokwim Delta, Alaska Mixed carriage and invasive isolates, P 95 3 mo A SP NS c U NS c U [29] Durban, South Africa Hosp, P 81 1 mo B 4.2 U [30] Malmöhus County, Sweden DCC, P, RO mo A TS Amp or AX [31] Kentucky DCC, P wk A NS U [32] Toronto DCC, P 586 CAU 1mo [33] France B, RTT [34] France B, RTT d d 13 d 13 d [35] Athens, Greece DCC, P mo 3mo [36] Memphis Ped pract, P mo 2mo 3mo A A CT AC CX AC A A b b b 1.6 U, 1.6 M 2.5 b U, 2.15 b M (0.7) (1.1) (1.43) d U (6.4) b U e (2.7) b U d (1.46) (4.31) b (0.82) (0.36) b (1.6) f (6.7) b (1.1) (0.3) b (5.6) b U (1.9) U (2.7) b U (1.9) U (1.6) U (3.2) U (1.1) U [38] Denver DCC, P, RO 62 2 mo A (7.3) b U [39] Cleveland DCC, P, RO mo 3 A 7.3 b U [40] Loiret, France P, schools 941 g 30 days low b h low NP h low C h long b h long NP h 5.9 b U, 7.5 b M 6.7 b U, 9.6 b M 4.9 b U, 5.4 b M 3.5 b U, 3.9 b M 4.4 b U, 5.2 b M [41] Southern Israel DCC, LF, P 48 i 1 mo A 3.35 b M [43] France B, RTT d 7 14 d AC CP (4.1) b (0.36) b (4.1) b (0.55) b NOTE. Values shown in parentheses are not those given in the article cited but, rather, are calculated for the present article on the basis of the data described therein. A, antibiotics; AC, amoxicillin-clavulanate; Amp, ampicillin; AX, amoxicillin; B, before-after treatment; b, b-lactams; C, cephalosporin; CAU, current antibiotic use (at time of sampling); Cef, cefaclor; CP, cefpodoxime-proxetil; CT, ceftriaxone; CU, cefuroxime; CX, cefixime; DCC, day care center(s); E, erythromycin; Hosp, hospital; LF, longitudinal follow-up; M, multivariate analysis; NP, aminopenicillin; OR C ; conditional OR, as defined in text; P, prevalence study; Ped pract, pediatric practices; PTS, prospective treatment study; RO, study during outbreak of a resistant strain; RTT, randomized treatment trial; SP, specific classes; TS, trimethoprim-sulfamethoxazole; U, univariate analysis (for observational studies). a Time prior to culture during which antibiotic risk factor is measured. b Statistically significant at P!.05; otherwise, not statistically significant. c No numbers given, but paper states association was not significant. d Multivariate association was not significant, as reported in the article. e Multivariate association was also significant, as reported in the article. f Before calculations based on colonized individuals only in both groups. g Only 54 carriers were detected, possibly because of oropharyngeal cultures. h Significant associations found only with low or long doses. i Multiple measurements per child.

9 risk factors for antibiotic-resistant infection or colonization. A practical goal of these studies is to identify changes in prescribing practices or choices of antibiotics that will maximize the life expectancy of existing antibiotics while maintaining appropriate treatment for individual patients. A related goal is to document the risks of inappropriate treatment, both to the treated patient and to others in the community, to motivate more judicious antibiotic use [44, 45]. Accomplishing these goals requires careful attention to the study design and interpretation. Although the reported results of differently designed studies that examine the effect of antibiotic treatment on resistance have been quite heterogeneous, the conclusions are in fact fairly consistent if the relevant characteristics of the studies are isolated. Treatment repeatedly has been shown to be a risk factor for infection or colonization with penicillin-resistant (as opposed to penicillin-susceptible) pneumococci, but it has rarely been shown to increase a patient s absolute risk for penicillin-resistant colonization or infection. The largest exceptions to the latter generalization occur during outbreaks of a resistant organism, as predicted by our model. Antibiotics differ in their effects on nasopharyngeal carriage of both susceptible and resistant organisms; for example, amoxicillin-clavulanate repeatedly has been shown to reduce the carriage of resistant and susceptible organisms, whereas other drugs have shown little effect on carriage of either. The importance of selecting the correct comparison group for studies of use of antimicrobial agents and resistance recently has been noted for other bacterial species [46, 47]. In many circumstances, treatment will increase only slightly (or may even decrease) carriage of resistant organisms in the treated patient. Furthermore, even when there is an effect on the patient, it will be relatively short-lived (figure 2); this prediction was confirmed in a recent study of resistance to trimethoprim-sulfamethoxazole (TMP-SMX) in Malawi [7]. If treatment produces, at most, a small and short-lived increase in resistance in the patient, how does it create selective pressure for resistance in the community? The answer, alluded to above, is that although treatment may reduce or only slightly increase carriage of resistant organisms, it typically has a considerably larger effect in reducing carriage of susceptible organisms. When 2 populations of organisms compete for a resource (in this case, hosts to colonize), any circumstance that reduces the fitness of one population will increase that of its competitor. Although hosts can carry both susceptible and resistant organisms simultaneously, there is evidence from several sources that carriage of one strain can inhibit acquisition of other strains, resulting in competition for hosts [4, 5]. In terms of mathematical models for the spread of antibiotic resistance in a population, resistant organisms will increase in frequency, roughly speaking, when their basic reproductive number ( R ) is greater than that of susceptible ones. R for 0 0 each type is given by the transmission rate constant for that type (b) multiplied by the average duration of carriage of that type. If treatment is more effective in clearing susceptible organisms than in clearing resistant ones, then an increase in rates of treatment in the community at large will result in a greater decline in R0 for susceptible organisms than in R0 for resistant ones. As a result, if treatment becomes sufficiently frequent, it will result in an increase in the frequency of resistant organisms. Although the principles described in the present report should apply to any antibiotic or class and its corresponding resistance in pneumococcus, there may be important differences. At least 3 intervention studies have examined the effect of other drugs: azithromycin in 2 cases [9, 10] and TMP-SMX in a third [7]. In these cases, carriage of organisms resistant to the drug used for treatment increased significantly after treatment, compared with before ( OR S 1 1). It will be important to understand why this phenomenon seems to be more frequent in these other drug classes (albeit in a limited number of studies) than for resistance to b-lactams and penicillin. Part of the explanation at least for TMP-SMX may be that outgrowth of resistant subpopulations is relatively frequent compared to killing of resistant organisms; this is consistent with the results of Feikin et al. [7], who measured these processes separately. Furthermore, it may be relatively easy for some b-lactams or cephalosporins to eradicate an organism that has been defined as nonsusceptible [48, 49] because susceptibilities (MICs) to these drugs form a relatively smooth continuum, in contrast to macrolides, for example, in which there are fairly sharp breaks in MICs between susceptible and resistant isolates [50]. Randomized studies of antibiotic use and resistance have 2 important advantages over most observational studies. First, they allow investigators to separate the different effects of treatment: (1) killing susceptible organisms; (2) in some cases, allowing for the outgrowth of resistant subpopulations; and (3) possibly increasing susceptibility to future colonization with a resistant strain. Such knowledge is important as the scientific community attempts to understand the impact of treatment at the community level. Second, randomized intervention studies avoid many of the problems of confounding and reverse causality that can cloud the interpretation of observational studies. For example, in an observational study, confounders such as age and day care attendance might produce a spurious association between use of antimicrobial agents and carriage of resistant organisms. A randomized intervention study would reduce this confounding. Alternatively, multivariate methods can be used to control for such confounding in observational studies. These studies raise a practical question: how can an antibiotic regimen be chosen that will not only be effective in treating 1052 CID 2001:32 (1 April) Lipsitch

10 the patient s infection but will also: (1) minimize the probability that the treated patient will subsequently develop resistant infection, and (2) minimize the selective pressure for resistant pneumococci in the community as a whole? OR S is an appropriate measure of the direct effect of treatment on a patient s own risk of resistant infection, so drug regimens that produce the lowest value for this measure, perhaps by killing relatively resistant organisms, may be preferable for the patient. From the perspective of the community, the choice is more complicated for 2 reasons. The first reason was given above: even a drug that kills resistant organisms can nonetheless exert selection in favor of resistance, if it is more effective against susceptible ones. Future work in mathematical modeling should address the relative merits (at a population level) of, for example, a drug that is highly effective against susceptible organisms (producing marked selection in favor of resistance) but that also clears carriage of resistant ones (reducing the selective benefits of resistance), in comparison with a drug that is less effective against carriage of susceptible organisms but that also rarely kills resistant ones. Second, at the community level, one effect of using a drug that can kill resistant organisms may be to select for still higher levels of resistance, which places a microorganism beyond the reach of even the more potent antibiotic. In vitro and animal studies [51, 52] suggest that more potent treatment regimens can select for ever-higher MICs, whereas less potent ones will provide little selective advantage for MICs higher than those required to resist drug action. 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