Impact of Inadequate Empirical Therapy on the Mortality of Patients with Bloodstream Infections: a Propensity Score-Based Analysis

Abstract

The impact of the adequacy of empirical therapy on outcome for patients with bloodstream infections (BSI) is key for determining whether adequate empirical coverage should be prioritized over other, more conservative approaches. Recent systematic reviews outlined the need for new studies in the field, using improved methodologies. We assessed the impact of inadequate empirical treatment on the mortality of patients with BSI in the present-day context, incorporating recent methodological recommendations. A prospective multicenter cohort including all BSI episodes in adult patients was performed in 15 hospitals in Andalucía, Spain, over a 2-month period in 2006 to 2007. The main outcome variables were 14-and 30-day mortality. Adjusted analyses were performed by multivariate analysis and propensity score-based matching. Eight hundred one episodes were included. Inadequate empirical therapy was administered in 199 (24.8%) episodes; mortality at days 14 and 30 was 18.55% and 22.6%, respectively. After controlling for age, Charlson index, Pitt score, neutropenia, source, etiology, and presentation with severe sepsis or shock, inadequate empirical treatment was associated with increased mortality at days 14 and 30 (odds ratios [ORs], 2.12 and 1.56; 95% confidence intervals [95% CI], 1.34 to 3.34 and 1.01 to 2.40, respectively). The adjusted ORs after a propensity score-based matched analysis were 3.03 and 1.70 (95% CI, 1.60 to 5.74 and 0.98 to 2.98, respectively). In conclusion, inadequate empirical therapy is independently associated with increased mortality in patients with BSI. Programs to improve the quality of empirical therapy in patients with suspicion of BSI and optimization of definitive therapy should be implemented.T he empirical antibiotic treatment of patients with potentially serious infections is a challenging task. Providing appropriate empirical coverage is proving more and more difficult as antibiotic resistance increases in both the hospital and the community (1). In such situations, physicians face a dilemma: to provide a very-broad-spectrum empirical coverage, accepting that on many occasions it will be excessive and might contribute to further resistance selection, or to use a narrower-spectrum empirical regimen, accepting that it may not cover the causative pathogen and might require correction once the susceptibility results are known (19).A key aspect of this decision-making process is the prognostic impact of empirical therapy. A meta-analysis recently showed reduced mortality rates for sepsis patients who received appropriate empirical therapy (22), although the studies analyzed were heterogeneous in terms of populations and types of infection covered. In both this study and another systematic review focusing on the methodological aspects of the topic (18), the need for new studies with improved methodologies was outlined. Bloodstream infection (BSI) has some advantages as a model for this kind of research. Although patients with bacteremia are only a subset of the pool of patients suffering ...

Epidemiology and microbiology of nosocomial bloodstream infections: analysis of 482 cases from a retrospective surveillance study

“…The Pitt bacteremia score is a marker of severity of illness in patients with nBSIs and patients with scores >4 are considered to be critically ill. In line with the results of previous studies (Neuner et al, 2011;Retamar et al, 2011;Melzer and Welch, 2013), in our hospital the Pitt bacteremia score was strongly correlated with 28-d mortality. Compared with CLABSI, we demonstrated a significant association between urinary tract source of BSI and death at 28 d. This result has also been validated in a multi-center study in the UK (Melzer and Welch, 2013).…”

http://www.omicsonline.org/open-access/thrombotic-thrombocytopenic-purpura-complicating-severe-legionnaires-disease-2161-0703.1000138.php?aid=28484

“…Any delay in provision of empirical antibiotic therapy of an invasive infection is associated with increased mortality [15] and it is known that early adequate treatment of BSI caused by an enterococcus is crucial to patient survival [12]. Our study demonstrates that very basic clinical observations and simple laboratory parameters can be used to help decide on the appropriate antibiotic treatment of BSI caused by Gram positive cocci in chain.…”

Bacterial sepsis

“…Using fully automated testing of pathogen-positive blood samples, a large number of gram-positive and gram-negative pathogens (as well as Candida species) can be identified, and the MCI of classical broad-spectrum antibiotics can be tested. According to the manufacturer, the identification of the pathogen in positive blood samples succeeds within 90 min; the results of susceptibility testing are available within 7 h. This technique therefore appears suitable for significantly reducing the time interval between empirical and targeted pathogen-specific (MIC-adapted) treatment, and thus also for reducing the increased mortality of patients who receive inadequate initial treatment of bacteremia (bloodstream infection, BSI; [99,100]). The possibility of early adaptation of the anti-infective therapy is drawing nearer.…”