Marisa's policy paper

Restrictions on Fluoroquinolones in Hospitals
A hospital’s purpose is to help fix our medical problems, not to create another. In the emergency rooms of hospitals, fluoroquinolones are being used in inappropriate amounts. A research done at a hospital showed that 80% of fluoroquinolones were used improperly, and 90% of the patients were given levofloxacin when ciprofloxacin could have been used (3). Ciprofloxacin was one of the first developed of the fluoroquinolones and it gained fame for fighting off MRSA very well. There was a study done on MRSA in patients and was noted that the bacteria in some of the patients were becoming resistant to ciprofloxacin. Then levofloxacin was created to become the new and improved ciprofloxacin to fight against gram-positive pathogens, but also had resistance from MRSA. A study on levofloxacin and ciprofloxacin was performed and concluded that levofloxacin, a stronger quinolone is much more likely to promote MRSA (1).
Fluoroquinolones such as levofloxacin and ciprofloxacin are among the most prescribed antimicrobial drugs in the hospital because they actively kill bacteria by inhibiting reproduction (1). They target DNA gyrase and topoisomerase IV, which are enzymes vital to bacterial growth and survival (5). Until 1998, it was thought that resistance to quinolones could only be through mutations, but it is not the case anymore. The gene qnrA, which is plasmid born can prevent the quinolone from attacking the DNA gyrase. The spread of this plasmid could further the development of higher-level resistance to quinolones of bacteria that are considered susceptible (4).
In another study, it was statistically shown that the usage of fluoroquinolones used in hospitals increased between the years 1999 and 2003. The resulting factor was that resistance to fluoroquinolones increased when the dose increased (2). MRSA increased its resistance to fluoroquinolones from 42% in 1999 to 51% in 2003, thus, resulting in patients that contracted MRSA from a resistance to fluoroquinolone (2). Therefore, if there were not an increase in usage, a higher percentage of resistance would not have occurred.

As Bert Fish Medical Center’s administrator, I have determined a policy to help protect our patients from bacterial resistance to fluoroquinolones that we use in the ER.
1. The patient needs to have a bacterial infection for ciprofloxacin to be used on them. If there is no bacterial infection, no type of fluoroquinolone will be used on the patient.
2. We will only use ciprofloxacin in doses of a maximum of 1000 mg so resistance will be minimal if any.
3. Levofloxacin will only be used when ciprofloxacin has no apparent affect on the bacterial infection of the patient.
4. Levofloxacin can only be used in doses of a maximum of 500 mg to minimize resistance that could occur.
5. If a patient is to be found with traces of fluoroquinolones in their system when they were not diagnosed with a bacterial infection, the staff working with the patient will be put on probation.
6. The staff is able to appeal the allegations in front of the hospital board and hospit
al administrators if a second or third violation occurs. Either violation found guilty could result in a dismissal from their current position.
This policy will help decrease the amount of resistance of bacteria found in patients, which will decrease their chances of obtaining MRSA after an operation in our ER. An argument to this policy would be if the patient had a very rapid growing bacterial infection and it was known, the staff would not be able to use levofloxacin until they used ciprofloxacin, which may not work as fast or at all. Some bacterial infections are not as life threatening as MRSA is, so preventing a resistance from MRSA can be more beneficial to the patient than actually fighting the infection full blown with a dose of the more powerful drug levofloxacin. Another opposing viewpoint would be that people want to prevent bacterial infections from occurring so why should they need to wait to contract the infection to be able to get the antibiotic. Trying to prevent an infection before it occurs only allows other strains of bacteria to become resistant faster to the antibiotic. It becomes an overuse of the drug, which has a greater development rate of resistance. This policy is needed to decrease the risk of MRSA in our patients by reducing the amount of resistance that can occur.

1) “Fluoroquinolones and the Risk for Methicillin-resistant Staphylococcus aureus in Hospitalized Patients.” Emerging Infectious Disease. Nov. 2003. 5 Oct. 2008 < >.
2) MacDougall, C. “Pseudomonas aeruginosa, Staphylococcus aureus, and Fluoroquinolone Use.” MEDLINE. Aug. 2005. OCLC. 5 Oct. 2008 <>.
3) Pfeiffer, Naomi. “Fluoroquinolone misuse in ER creates concern.” Health Source: Nursing/Academic Edition. July 2001. EBSCO. 5 Oct. 2008 <>.
4) Robicsek, A, et al. “Broader Distribution of Plasmid-Mediated Quinolone Resistance in the United States.” Pub Med Central. 2005. American Society for Microbiology. 5 Oct. 2008 <>.
5) Roychoudhury, Siddhartha. “Quinolone Resistance in Staphylococci: Activities of New Nonfluorinated Quinolones against Molecular Targets in Whole Cells and Clinical Isolates.” American Society for Microbiology. 2001. 5 Oct. 2008 <>.

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