Appropriateness of antimicrobial use among septic patients managed by the critical care response team: an opportunity for improvement through de-escalation

Abstract

BackgroundMost septic patients managed by critical care response teams (CCRT) are prescribed antimicrobials. Nevertheless, data evaluating their appropriateness are lacking both locally and internationally. The objective was to assess antimicrobial use among septic and non-septic patients managed by CCRT.SettingCase-control design was used to compare septic (cases) and non-septic (controls) CCRT patients at tertiary care setting. The frequency of antimicrobial use was assessed before and after CCRT activation. The appropriateness of antimicrobial use was assessed at day four post-CCRT, based on standard recommendations, clinical assessment, and culture results.Main resultsA total of 157 cases and 158 controls were included. The average age was 61.1 ± 20.4 years, and 54.6% were males, with minor differences between groups. The use of any antimicrobial was 100.0% in cases and 87.3% in controls (p < 0.001). The use of meropenem (68.2% versus 34.8%, p < 0.001) and vancomycin (56.7% versus 25.9%, p < 0.001) were markedly higher in cases than controls. The overall appropriateness was significantly lower in cases than controls (50.7% versus 59.6%, p = 0.047). Individual appropriateness was lowest with meropenem (16.7%) and imipenem (25.0%), and highest with piperacillin/tazobactam (87.1%) and colistin (78.3%). Only 48.5% of antimicrobials prescribed by CCRT were de-escalated by a primary team within four days. Individual appropriateness and de-escalations were not different between groups.ConclusionsEmpiric use and inadequate de-escalation of broad-spectrum antimicrobials were major causes for inappropriate antimicrobial use in CCRT patients. Our findings highlight the necessity of urgent implementation of an antimicrobial stewardship program, including training and auditing of antimicrobial prescriptions.

How Antibiotics Stewardship Can Be Safely Implemented in Patients with Septic Shock?

“…41 Moreover, more than 50% of antibiotics prescribed by a critical care response team for a pathogen-negative sepsis are not stopped. 42 In another study, the median duration of empiric antibiotics (interquartile range) among 1,047 survivors with pathogen-negative sepsis was 6 (4-9) days. 43 In the same cohort study, early stop of antimicrobial treatment was associated with a better prognosis.…”

Days of Antibiotic Spectrum Coverage Trends and Assessment in Patients with Bloodstream Infections: A Japanese University Hospital Pilot Study

“…Additionally, the de-escalation strategy has not been sufficiently evaluated because of its unclear definition [ 9 , 10 , 11 , 12 ]. Previous studies evaluated de-escalation strategy by antimicrobial stewardship interventions, although each study’s definition varied [ 13 , 14 , 15 , 16 , 17 ].…”