Assessment of empirical antibiotic therapy optimisation in six hospitals: an observational cohort study

Abstract

Summary Background Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy. Methods We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0.1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable. Findings Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05–2·70) and no infection was noted on an initial radiological study (1·76, 1·11–2·79). Escalation was associated with multiple infection sites (2·54, 1·34–4·83) and a positive culture (1·99, 1·20–3·29). Interpretation Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials. Funding US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security.

A Study of Unnecessary Use of Antibiotics at a Tertiary care hospital: Urgent need to implement antimicrobial stewardship programs

“…It is evident that optimal antimicrobial use is linked with collection of cultures before prescribing the antimicrobial. 24 Another study demonstrated that timely bacteriological results are connected with decrease time to start effective therapy and reduction of 6 days in hospital stay. 25 By implementing this practice, a large number of inappropriate and unnecessary antibiotics could be avoided.…”

Best practice for sepsis

“…A recent study reported that the implementation of antibiotic/ sepsis bundles in patients with a sepsis code was associated with increased Clostridium difficile infection rates (5). Here is where diagnostic tests have an important role and a policy of antimicrobial stewardship focusing on reduced exposure to broad-spectrum antibiotic needs to be implemented (6).…”

“…In addition, 20% of these patients were already on antibiotics before presentation and all of them have short hospital arrival times. As described in demography, the intervention focused on patients with different levels of severity-of-illness (38% with infection, 57% with severe sepsis and 4% with septic shock), being patients with septic shock or organ dysfunction a small proportion (6). Moreover, time to initiation of appropriate antibiotic prescription was not reported, but due to the low rate of resistances in the Netherlands, it was expected to be small, in contrast with other geographical regions with spread rate of resistances, particularly in Enterobacteriaceae.…”

Bacterial sepsis

“…Moreover, in retrospective analyses it could be shown that in only about 30% of patients did the initial calculated antibiotic therapy actually encompass the pathogen, and de-escalation of therapy was only undertaken in a third of patients [127][128][129][130][131][132][133]. Combining broad-spectrum antibiotics simultaneously potentiates the selective pressure on pathogens and leads to increased development of resistance [134].…”