Antimicrobial cycling: lessons learned from the aminoglycoside experience

Area of Science:

• Microbiology
• Infectious Diseases
• Pharmacology

Background:

• Antimicrobial resistance is a growing global health threat.
• Several strategies exist to combat resistance, including antimicrobial stewardship and drug rotation.
• Cyclic or rotational use of antimicrobials aims to reduce resistance by periodically removing certain agents from the environment.

Purpose of the Study:

• To evaluate the effectiveness of a rotational antimicrobial strategy in reducing microbial resistance.
• To examine data from a long-term aminoglycoside substitution study for insights into rotational therapy.
• To provide guidance for designing future studies on antimicrobial rotation.

Main Methods:

• Analysis of a 10-year hospital-wide study rotating amikacin and gentamicin use.
• Observation of resistance patterns during sequential cycles of aminoglycoside administration.
• Critical examination of the study design and identification of potential pitfalls.

Main Results:

• Rotating amikacin and gentamicin use led to significantly reduced gentamicin resistance when amikacin was administered.
• Gentamicin resistance re-emerged upon returning to gentamicin use but decreased again with subsequent amikacin reintroduction.
• A second reintroduction of gentamicin did not result in recurring resistance, suggesting potential efficacy.

Conclusions:

• Rotational antimicrobial use, specifically with aminoglycosides, shows evidence of reducing microbial resistance.
• The strategy appears most applicable to drugs targeting gram-negative bacilli due to available alternatives.
• Future research should focus on multicenter controlled trials with careful monitoring of outcomes and resistance patterns.