Impact of Appropriate Antimicrobial Therapy for Patients with Severe Sepsis and Septic Shock – A Quality Improvement Study

Abstract

BackgroundThere is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes.MaterialThis study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock.ResultsA total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023).ConclusionsThe administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.

Recommendations for infection management in patients with sepsis and septic shock in resource-limited settings

“…Hospital, and especially ICU-related, infections are more likely to be caused by multidrug-resistant organisms and previous antibiotic use is a risk factor for antibiotic resistance. Misdirected initial antibiotic therapy is associated with poor outcome [2, 3], but there is a paucity of epidemiological data in most low-resourced settings. We recommend empirical antibiotic therapy should cover all expected pathogens and likely resistance patterns (1C) based on locally-acquired epidemiological data as large regional variations exist (ungraded).…”

“…There is weak evidence from resource-limited settings suggesting that timely administration of antibiotics is beneficial [2, 4–6]. Observational data suggest that, in many resource-limited settings, the administration of antibiotics to most patients within 1 h of sepsis or septic shock recognition is feasible.…”

Epidemiology and Outcome Among Severe Sepsis and Septic Shock Patients in a South Indian Tertiary Care Hospital

“…Antibiotic resistance is emerging as a serious problem due to inappropriate antibiotic use in both grams negative and gram positive organisms. Appropriate antibiotic administration on admission to the emergency department has been reported to improve the quality of life and survival among the patients [9,10]. In view of the emergence of gram-negative organisms, especially the multidrug resistant strains, there is an urgent requirement for antimicrobial stewardship programs [16,17].…”

“…The increased life expectancy of individuals (including those who are immune-compromised) and the surge seen with the utilization of invasive medical interventions are all important contributors to the high incidence of sepsis and its complications. International guidelines highlight the need for early identification of the condition and prompt implementation of the treatment, including antibiotics to reduce the serious consequences [8][9][10][11][12][13]. It has been observed that prompt administration of antibiotics and improve outcomes in patients with sepsis.…”

Individualized antibiotic strategies

“…In logistic regression analyses, non-IAAT was strongly associated with MDR and identified as an independent predictor of hospital mortality. In another retrospective study, a total of 1279 patients with severe sepsis and septic shock were identified; of which 32% had bloodstream infections [14]. In these patients, the administration of appropriate antimicrobial therapy was associated with a decrease in hospital mortality, even after adjustment for other covariates.…”