Toltzis P et al
2002
|
Controlled trial
|
Neonatal ICU
|
Monthly cycling of gentamicin, piperacillin-tazobactam and ceftazidime
for suspected infections due to Gram-negative pathogens versus standard
practice in the control group (usually ampicillin and gentamicin for
suspected infection at birth, vancomycin and gentamicin for
hospital-acquired infection, ampicillin and cefotaxime for meningitis,
and piperacillin-tazobactam for necrotizing enterocolitis)
No de-escalation
Typing to assess clonality of bacterial isolates
|
PRIMARY
Similar incidence of colonization with resistant bacilli to any
antibiotic
Similar incidence of colonization with resistant bacilli to the rotated
antibiotics (even when only data regarding clonally discordant isolates
were considered)
OTHER
On-cycle antibiotic use 84.3% for the rotation team
Predominant use of gentamicin in the control team
Similar overall antibiotic use
Similar length of stay
|
Unit-wide surveillance cultures
|
Cadena J et al
2007
|
Before-and-after
|
Haematology-Oncology Unit
|
Cycling of piperacillin-tazobactam and cefepime for the empirical
therapy of neutropenic fever every three months versus standard practice
during a baseline period (not further clarified)
Potential of de-escalation not clarified
No typing of bacterial isolates to assess clonality
|
PRIMARY
Inconclusive changes in relevant susceptibilities of Enterobacterales
and P. aeruginosa
Decrease in ampicillin-susceptible Enterococcus spp,
erythromycin- and clindamycin-susceptible S. aureus
OTHER
Increase in cefepime and piperacillin-tazobactam consumption index from
0.003 to 0.88
Increase in cefepime use
|
Unit-wide clinically indicated cultures
|
Bennett KM et al
2007
|
Before-and-after
|
Surgical ICU
|
Cycling of piperacillin-tazobactam, imipenem, ceftazidime and
ciprofloxacin every month for the empirical treatment of suspected
Gram-negative infections (Ciprofloxacin discarded later) versus standard
practice during a baseline period (not further clarified)
De-escalation permitted
No typing of bacterial isolates to assess clonality
|
PRIMARY
Increase in piperacillin-tazobactam and ceftazidime-susceptible P.
aeruginosa proportions; No changes for the Medical ICU (Used as a
comparison unit)
Inconclusive changes for E. coli and K. pneumoniae in the
Surgical ICU; Increase in piperacillin-tazobactam-resistant E.
coli proportions and inconclusive changes for K. pneumoniae in
the Medical ICU
OTHER
No information provided regarding secondary outcomes
|
Unit-wide clinically indicated cultures
|
Smith R et al
2008
|
Before-and-after
|
Surgical ICU
|
Cycling of vancomycin and linezolid for suspected Gram-positive
infections every three months versus primary vancomycin use during a
baseline period
De-escalation permitted
No typing of bacterial isolates to assess clonality
|
PRIMARY
Decrease in MRSA incidence rates during cycling
Similar VRE incidence rates
OTHER
Similar percentage of in-hospital deaths according to initial empirical
therapy
Similar incidence rates of C. difficile colitis
|
Unit-wide clinically indicated cultures
|
Nijssen S et al
2009
|
Prospective comparative cross-over trial
|
2 ICUs
(Medical ICU and Neurosurgery ICU)
|
Weekly cycling of ceftriaxone, amoxicillin-clavulanate and levofloxacin
or ciprofloxacin as empirical treatment versus the homogeneous
administration of ciprofloxacin or levofloxacin
No de-escalation
Typing of isolates to exclude clonal outbreaks
|
PRIMARY
Higher colonization rates for ciprofloxacin-resistant isolates
(including ciprofloxacin-resistant cephalosporin-resistant isolates)
during the homogeneous period
Similar colonization rates for cephalosporin-resistant
Enterobacteriaceae
OTHER
Similar overall antibiotic use
Higher ciprofloxacin use during the homogeneous period
Lower third-generation cephalosporin use during the homogeneous
period
|
Unit-wide surveillance cultures
|
Raineri E et al
2010
|
Before-and-after
|
2 ICUs
|
Cycling of piperacillin-tazobactam, fluoroquinolones, carbapenems,
cefepime/ceftazidime every three months for the empirical treatment of
VAP versus standard practice in a baseline period (most commonly
piperacillin-tazobactam or levofloxacin)
No de-escalation
No typing of bacterial isolates to assess clonality
|
PRIMARY
Similar incidence of VAP due to antibiotic-resistant bacteria
Decrease in cefepime- and aminoglycoside-resistant P. aeruginosa
isolates
Decrease in cefazolin-resistant K. pneumoniae and E. coli
isolates from
No other conclusive changes
OTHER
On-cycle antibiotic use 83% in Unit 1 and 88% in Unit 2
Increase in carbapenem and extended-spectrum penicillin use
Decrease in aminoglycoside, fluoroquinolone, 3GC and 4GC use
Similar mortality rates
|
Respiratory cultures derived from Ventilator-associated Pneumonia
cases
|
Cumpston A et al
2012
|
Before-and-after
|
Blood and Marrow Transplantation Unit
|
Pre-cycling period: No prophylaxis for neutropenia;*
Piperacillin-tazobactam for the empirical treatment of febrile
neutropenia
Period A: Cycling of imipenem, cefepime plus+ tobramycin and
piperacillin-tazobactam plus tobramycin every eight months for the
empirical treatment of febrile neutropenia; Levofloxacin as prophylaxis
for neutropenia*
Period B: Cycling of agents every three months;
Addition of tobramycin in the imipenem arm; Levofloxacin as prophylaxis
for neutropenia*
*Addition of vancomycin at the discretion of the clinician
De-escalation permitted
No typing to assess clonality of bacterial isolates
|
PRIMARY
Increase in quinolone-resistant Enterobacterales incidence rates
Increase in VRE incidence rates
No other conclusive changes in resistance patterms
OTHER
Decrease in vancomycin use
Similar use of cefepime, piperacillin-tazobactam and imipenem across the
four most recent years of cycling
Decrease in incidence rate of Klebsiella and E. coli
bacteremia and candidemia
Similar morbidity and mortality incidence rates
|
Unit-wide blood cultures
|
Chong Y et al
2013
|
Before-and-after
|
Haematology Unit
|
Monthly cycling of piperacillin-tazobactam, ciprofloxacin, meropenem and
cefepime for the empirical treatment of neutropenic fever versus the
homogeneous use of cefepime during a baseline period
Potential of de-escalation not clarified
No typing of bacterial isolates to assess clonality
|
PRIMARY
Blood isolates: Decrease in cefepime-resistant isolate incidence from
6/13 (70% of those were ESBLs) to 01/14 (p=0.007); Decrease in
ciprofloxacin-resistant isolate incidence
Stool isolates: Decrease in ESBL and ciprofloxacin-resistant E.
coli incidence
OTHER
Similar mortality rates
65.9% decrease in unit-wide cefepime-use
|
Blood and stool cultures from patients with neutropenic fever
|
Teranishi H et al
2017
|
Before-and-after
|
Paediatric Haematology Unit
|
Monthly cycling of piperacillin-tazobactam, meropenem and cefepime
versus the homogeneous prescription of cefpirome as empirical treatment
for neutropenic fever during a baseline period
No de-escalation
No typing of bacterial isolates to assess clonality
|
PRIMARY
Blood isolates: Decrease in ESBL incidence from 5/15 to 0/15 isolates
(p< 0.05)
Nasal and stool isolates: Decrease in ESBL incidence from 15/33 to 0/33
isolates (p<0.01)
Similar MRSA and VRE incidence
OTHER
No information provided regarding secondary outcomes
|
Blood, nasal and stool cultures from patients with neutropenic
fever
|
Tsukayama D et al
2004
|
Comparative trial
|
ICU
|
Cycling of ciprofloxacin or levofloxacin plus clindamycin or
metronidazole with piperacillin-tazobactam every four months as
first-line empirical treatment
De-escalation permitted
Typing to assess clonality of bacterial isolates
|
PRIMARY
No correlation between particular antibiotic class consumption and onset
of resistance
OTHER
Off-cycle antibiotic use not drastically reduced
|
Unit-wide surveillance units
|
Van Loon H et al
2005
|
Comparative trial
|
ICU
|
Cycling of levofloxacin plus aminoglycoside with beta-lactam plus
aminoglycoside (cefpirome in one cycle and piperacillin-tazobactam in
the other) every four months for suspected Gram-negative infections
No de-escalation
No typing of bacterial isolates to assess clonality
|
PRIMARY
Colonization rates for Gram-negative bacteria resistant to levofloxacin
higher in periods of exposure
Colonization rates for Gram-negative bacteria resistant to cefpirome
similar between periods of exposure and non-exposure
Colonization rates for Gram-negative bacteria resistant to
piperacillin-tazobactam higher in periods of exposure
OTHER
On-cycle antibiotic use 88.5%-100%
|
Unit-wide surveillance cultures
|
Ginn A et al
2012
|
Comparative trial
|
2 ICUs
|
Cycling of piperacillin-tazobactam and cefepime for the empirical
therapy of sepsis every four months
Potential of de-escalation not clarified
Typing of isolates to exclude clonal outbreaks
|
PRIMARY
Proportion of admissions complicated by antibiotic-resistant isolates
higher in cefepime cycles
Proportion of admissions complicated by MRSA higher in cefepime cycles
OTHER
Similar risk of admissions complicated by any infection
On-cycle antibiotic use>60% of total use
Off-cycle antibiotic use<15% of total use
|
Unit-wide clinically indicated cultures
|
Martinez J et al
2006
|
Comparative cross-over trial
|
2 ICUs
|
1st arm: Cycling of cefepime (or ceftazidime),
ciprofloxacin, carbapenems, and piperacillin-tazobactam every month for
suspected Pseudomonas infections
2ndarm: Successive administration of these agents to
consecutive patients
Potential of de-escalation not clarified
Combination therapy permitted
No typing to assess clonality of bacterial isolates
|
PRIMARY
Higher proportion of patients colonised with cefepime-resistant P.
aeruginosa during mixing
Inconclusively higher proportion of ceftazidime and carbapenem-resistant
P. aeruginosa during mixing (p=.
0.06 and 0.07 respectively)
No other significant differences with regard to other Gram-negatives
species
OTHER
Higher mortality rates during cycling only for Unit 2
Similar mortality rates during cycling and mixing for Unit 1
Higher use of carbapenems and piperacillin-tazobactam and lower use of
cephalosporins during mixing
|
Unit-wide surveillance cultures
|
Van Duijn PJ et al
2018
|
Cluster randomised cross-over trial
|
Multi-centre ICU
|
Cycling of 3GC (or 4GC), carbapenems and piperacillin-tazobactam every
six weeks versus mixing those agents (administering those successively
to consecutive patients) for empirical treatment of suspected
Gram-negative infections
De-escalation permitted
Combination therapy permitted
No typing to assess clonality of bacterial isolates
|
PRIMARY
Similar prevalence of antibiotic-resistant Gram-negative bacteria
Similar incidence rate ratio of antibiotic-resistant Gram-negative
bacteria adjusted for hand hygiene compliance, patient-sex and
proportion of short-stay patients
Similar prevalence of ESBLs, piperacillin-tazobactam- or
carbapenem-resistant non-fermenters
OTHER
Similar mortality rates and similar length of stay during periods of
mixing and cycling
Similar overall use of antibiotics and similar use of study antibiotics
between study periods
Three times higher use of on-cycle antibiotics compared to off-cycle
use
|
Unit-wide surveillance cultures
|
Jayashree M et al
2020
|
Comparative trial
|
Paediatric ICU
|
Period 1: Mixing piperacillin-tazobactam, imipenem and cefepime
(administering those successively to consecutive patients) for suspected
Gram-negative infections
Period 2: Cycling the aforementioned agents every month
De-escalation permitted
Combination therapy permitted
No typing to assess clonality of bacterial isolates
|
PRIMARY
Higher percentage of resistant isolates during baseline period than in
mixing, cycling and washout periods
Similar percentage of resistant isolates during mixing and cycling
OTHER
Similar mortality rates between periods
Similar episodes of healthcare-associated infections during mixing and
cycling but lower than baseline
Similar overall use of antibiotics between all phases
|
Unit-wide surveillance cultures
|