ICU-acquired Nosocomial Infection: Impact of Delay of Adequate Antibiotic Treatment

Abstract

In order to measure the impact on survival of the early introduction of adequate antibiotic treatment for nosocomial bacteremia and pneumonia, a retrospective, cohort study was carried out over a period of 17 months in a 6-bed respiratory ICU. All patients presenting with a first episode of ICU-acquired nosocomial bacteremic infection (Centers for Disease Control criteria) or pneumonia [BAL culture > or = 10(4) colony-forming units (CFU)/ml or protected specimen brush culture > or = 10(3) CFU/ml] were included. The organ failure score (Fagon criteria) was recorded on the day of diagnosis. Adequate antibiotic treatment was defined by the sensitivity of each etiologic organism to at least 1 prescribed antibiotic. A total of 25 patients (Simplified Acute Physiology Score II = 44) were included in the study with pneumonia (n = 17) or bacteremia (n = 8), on average 6.5 +/- 4.6 d after admission. At the time of diagnosis, 23 patients were receiving mechanical ventilation. The overall mortality rate was 48% and was significantly associated with the length of time without adequate antibiotic treatment (p = 0.011) and the number of organ failures on the day of diagnosis (p = 0.017). Adequate antibiotic treatment only had an impact on survival if it was started within the first 24 h after sampling (p < 0.02 on Day 0 and < 0.04 on Day 1). On the day of diagnosis, a failure score > 2 was associated with increased mortality (p = 0.009). After adjusting for the number of organ failures, the length of time without adequate antibiotic treatment remained associated with mortality (< or = 2 organ failures, p < 0.02; > 2 organ failures, p = 0.05). This study suggests that, during the course of nosocomial pneumonia and bacteremia, the time at which adequate antibiotic treatment is started is a key factor influencing survival.

Nosocomial pneumonia in the ICU: A prospective cohort study

“…This may also be true for admission APACHE II score, which was not a risk factor for VAP in our study although severity of illness is often reported as a risk factor for VAP. Prompt treatment with appropriate broad-spectrum antibiotics in ICU patients with clinical signs of infection is a general accepted strategy, and does improve survival [10,14,16,26,27]. However, such treatment may reduce the chance to obtain a positive microbiological culture despite infection and thus may lead to an under-diagnosis of pneumonia [7].…”

“…In patients without VAP, the mortality was about half, but the 2 groups were not matched for severity of disease or comorbidities. A further confounder is that inadequate empiric antibiotics to patients with VAP will increase mortality [10,14,16,26,27], and the attributable mortality would be smaller with good standard of care including liberal bronchoscopic cultures and proper use of antibiotics. Patients with trauma had an increased risk of developing VAP but not to die within 28 d. Trauma patients are usually previously healthy and the median age was lower before admittance (43 y compared to 60 y for nontrauma patients), which may explain a more favourable outcome for these patients.…”

Antimicrobial susceptibility of uncommonly isolated non-enteric Gram-negative bacilli

“…In addition, these pathogens frequently cause disease in severely debilitated or immunocompromised patients [75]. Thus, mortality rates of NGB infections are generally high and the rapid introduction of appropriate empirical antimicrobial therapy remains crucial to improve clinical outcomes [3,5,10,69].…”

“…In addition, susceptibility testing methodologies are not standardised for most of these organisms, especially routine or automated commercial tests used in clinical microbiology laboratories, although some standard-defining organisations are actively seeking validated standardised methods [NC-CLS, 2005]. Thus, the knowledge of their epidemiology and antimicrobial susceptibility patterns is necessary to allow the development of empirical therapeutic strategies [10].…”

Intracerebral Hemorrhage Specific Intensity of Care Quality Metrics

“…Patients receiving delayed IV antibiotic treatment had greater hospital mortality compared with patients without the delay (70% versus 29%). Another study of 25 patients [199], observed that mortality increased if adequate antibiotic treatment was started after the first 24 h after diagnosis. After adjusting for the number of organ failures, the length of time without adequate antibiotic treatment remained associated with mortality.…”