Defining Antibiotic Inertia: Application of a Focused Clinical Scenario Survey to Illuminate A New Target for Antimicrobial Stewardship During Transitions of Care

Kooda, Kirstin; Bellolio, Fernanda; Dierkhising, Ross A.; Tande, Aaron J.

doi:10.1093/cid/ciab872

Cited by 5 publications

(4 citation statements)

References 13 publications

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“…Instead, our findings may represent evidence of diagnostic inertia. 52 Until practical guidance on how and when to re-evaluate ongoing need for antibiotics is built into formal protocols for sepsis care, such as the Centers for Medicare and Medicaid Services SEP-1 bundle, hospitals may encounter antibiotic overuse in this patient population.…”

Section: Discussionmentioning

confidence: 99%

Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients

Baghdadi

Goodman

Magder

et al. 2023

JAC-Antimicrobial Resistance

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Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur’s D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9–20.1), broad-spectrum (HR 10.3; 95% CI: 9.78–10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30–3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91–1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35–1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61–2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65–1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.

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Section: Discussionmentioning

confidence: 99%

Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients

Baghdadi

Goodman

Magder

et al. 2023

JAC-Antimicrobial Resistance

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“…9 Although interventions at this stage have been modestly effective, they face challenges including antibiotic inertia (eg, difficulty of discontinuing antibiotics after they have been started). 9,10 Comparatively fewer studies have examined diagnostic stewardship strategies for VAP antibiotic overuse—interventions at the level of diagnostic test ordering, collection, and reporting that can safely reduce ICU antibiotic overuse.…”

Section: Discussionmentioning

confidence: 99%

Healthcare providers consistently overestimate the diagnostic probability of ventilator-associated pneumonia

Soper

Albin

2023

Infect. Control Hosp. Epidemiol.

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Objective: To assess the accuracy of provider estimates of ventilator-associated pneumonia (VAP) diagnostic probability in various clinical scenarios. Design: We conducted a clinical vignette-based survey of intensive care unit (ICU) physicians to evaluate provider estimates of VAP diagnostic probability before and after isolated cardinal VAP clinical changes and VAP diagnostic test results. Responses were used to calculate imputed diagnostic likelihood ratios (LRs), which were compared to evidence-based LRs. Setting: Michigan Medicine University Hospital, a tertiary-care center. Participants: This study included 133 ICU clinical faculty and house staff. Results: Provider estimates of VAP diagnostic probability were consistently higher than evidence-based diagnostic probabilities. Similarly, imputed LRs from provider-estimated diagnostic probabilities were consistently higher than evidence-based LRs. These differences were most notable for positive bronchoalveolar lavage culture (provider-estimated LR 5.7 vs evidence-based LR 1.4; P < .01), chest radiograph with air bronchogram (provider-estimated LR 6.0 vs evidence-based LR 3.6; P < .01), and isolated purulent endotracheal secretions (provider-estimated LR 1.6 vs evidence-based LR 0.8; P < .01). Attending physicians and infectious disease physicians were more accurate in their LR estimates than trainees (P = .04) and non-ID physicians (P = .03). Conclusions: Physicians routinely overestimated the diagnostic probability of VAP as well as the positive LRs of isolated cardinal VAP clinical changes and VAP diagnostic test results. Diagnostic stewardship initiatives, including educational outreach and clinical decision support systems, may be useful adjuncts in minimizing VAP overdiagnosis and ICU antibiotic overuse.

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“…We are not aware of any published experience to date of a health care system specifically implementing the new ATS/IDSA recommendations. We chose to focus on the emergency department, because initial pneumonia diagnosis, risk stratification, and empiric antibiotic selection in the ED tend to determine subsequent inpatient antibiotic therapy (“antibiotic inertia”) and have a significant impact on overall antibiotic use 6–9 …”

Section: Introductionmentioning

confidence: 99%

“…We chose to focus on the emergency department, because initial pneumonia diagnosis, risk stratification, and empiric antibiotic selection in the ED tend to determine subsequent inpatient antibiotic therapy (“antibiotic inertia”) and have a significant impact on overall antibiotic use. 6 , 7 , 8 , 9 …”

Section: Introductionmentioning

confidence: 99%

Methicillin‐resistantStaphylococcus aureusandPseudomonas aeruginosacommunity acquired pneumonia: Prevalence and locally derived risk factors in a single hospital system

Frazee,

Singh,

Labreche

et al. 2023

JACEP Open

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ObjectivesCurrent American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) community‐acquired pneumonia (CAP) guidelines expand the CAP definition to include infections occurring in patients with recent health care exposure. The guidelines now recommend that hospital systems determine their own local prevalence and predictors of Pseudomonas aeruginosa and methicillin‐resistant Staphylococcus aureus (MRSA) among patients satisfying this new broader CAP definition. We sought to carry out these recommendations in our system, focusing on the emergency department, where CAP diagnosis and initial empiric antibiotic selection usually ooccur.MethodsWe performed a retrospective cohort study of patients admitted with CAP through any of 3 EDs in our hospital system in Northern California between November 2019 and October 2021. Inclusion criteria included an ED admission diagnosis of pneumonia or sepsis, fever or hypothermia, leukocytosis or leukopenia, and consistent chest imaging result. SARS‐CoV‐2‐positive cases were excluded. We abstracted variables historically associated with P. aeruginosa and MRSA. Outcome measures were prevalence of P. aeruginosa and MRSA in the overall clinically defined cohort and among microbiologically confirmed cases and predictors of P. aeruginosa or MRSA isolation, as determined by univariate logistic regression, bootstrapped least absolute shrinkage and selection operator, and random forest analyses. Additionally, we describe the iterative process used and challenges encountered in carrying out the new ATS/IDSA guideline recommendations.ResultsThere were 1133 unique patients who satisfied our definition of clinically defined CAP, of whom 109 (9.6%) had a bacterial pathogen isolated. There were 24 P. aeruginosa isolates and 11 MRSA isolates in 33 patients. Thus, the prevalence P. aeruginosa and MRSA was 2.9% in the overall CAP cohort, but 30.3% in the microbiologically confirmed cohort. The most important predictors of either P. aeruginosa or MRSA isolation were tracheostomy (odds ratio [OR] 22.08; 95% confidence interval [CI] 10.39–46.96) and gastrostomy tube (OR 14.7; 95% CI 7.14–30.26). Challenges included determining the suspected infection type in patients admitted simply for “sepsis”; interpreting dictated radiology reports; determining functional status, presence of indwelling lines and tubes, and long‐term care facility residence from the electronic health record; and correctly attributing culture results to pneumonia.ConclusionPrevalence of MRSA and P. aeruginosa was low among patients admitted in our medical system with CAP – now broadly defined – but high among those with a microbiologically confirmed bacterial etiology. Our locally derived predictors of MRSA and P. aeruginosa can be used to aid our emergency physicians in empiric antibiotic selection for CAP. Findings from this project might inform efforts at other institutions.

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Defining Antibiotic Inertia: Application of a Focused Clinical Scenario Survey to Illuminate A New Target for Antimicrobial Stewardship During Transitions of Care

Cited by 5 publications

References 13 publications

Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients

Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients

Healthcare providers consistently overestimate the diagnostic probability of ventilator-associated pneumonia

Methicillin‐resistantStaphylococcus aureusandPseudomonas aeruginosacommunity acquired pneumonia: Prevalence and locally derived risk factors in a single hospital system

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