Antibiotic Stewardship, Resistance, and Mortality in Vancomycin-Resistant Enterococcus: A Quasi-Experimental Study of Linezolid Restrictions

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ID: 332625
2026
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Ranked #536 of 635 articles by views in Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

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Abstract
BACKGROUND: Antibiotic restriction policies are intended to curb resistance, but their effects on resistance, timely treatment, and patient outcomes remain uncertain. We evaluated linezolid restrictions and whether vancomycin-resistant Enterococcus (VRE) screening identifies patients most likely to benefit. METHODS: We conducted a quasi-experimental difference-in-differences study using electronic health record data from 521,493 admissions at 2 academic medical centers from 2008 through 2019. Hospital 1 introduced a formal prior-authorization pager system in 2011 and stricter linezolid-specific criteria with enhanced post-prescription review in 2014; Hospital 2 served as a control. Outcomes included linezolid use, linezolid-resistant Enterococcus isolates, in-hospital mortality overall and by VRE status, and stewardship request behavior. RESULTS: Linezolid was used in 2.3% of admissions; 1.2% of Enterococcus isolates were linezolid resistant. Restriction policies were associated with a 27% reduction in linezolid use (-0.9 percentage points; 95% confidence interval, -1.1 to -0.7; P < .001) and a 41% reduction in resistance (-1.0 percentage points; 95% confidence interval, -1.6 to -0.4; P = .003). Overall mortality did not increase, but mortality among VRE-screen-positive patients increased by 4.7 percentage points (95% confidence interval, 1.9 to 7.5; P < .001), with larger increases among those with bacteremia or sepsis. Approval rates declined first, followed by fewer linezolid requests. CONCLUSIONS: Restriction policies can reduce antibiotic use and resistance but may benefit from screening-informed safeguards to preserve timely treatment for high-risk patients.
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Authors Edward L. Kong, David W. Kubiak, Erica Seiguer Shenoy, Alyssa R. Letourneau
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Journal Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Year 2026
DOI
10.1093/cid/ciag656
URL
https://doi.org/10.1093/cid/ciag656
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