Nonadherence to antibiotic guidelines in patients admitted to ICU with sepsis is associated with increased mortality

Abstract

BACKGROUND Early appropriate antibiotic therapy is an important component of the Surviving Sepsis Guidelines bundles that are associated with decreased in-hospital mortality. National antibiotic guidelines for the treatment of sepsis in Sweden have been available since 2008. Compliance with these guidelines is largely unknown, and whether it translates to improved patient outcome has not been studied. OBJECTIVE To assess mortality and its relationship to compliance with Swedish antibiotic guidelines. A secondary aim was to assess the effect of timing of antibiotic administration and mortality. DESIGN A registry-based, retrospective cohort study. Registry data were supplemented by manual extraction of data on antibiotic treatment from patient charts. The association between guideline compliance and mortality was evaluated using multivariable analysis. Three levels of compliance were predefined: full compliance – correct antibiotics and dose; partial compliance – correct antibiotic but wrong dose and/or wrong initial antibiotic but corrected within 24 h and/or wrong combination in a combined regime that is at least one antibiotic not in line with the national antibiotic guideline; no compliance – incorrect antibiotic. SETTING Two general ICUs in Sweden between 1 January 2011 and 31 December 2015. PATIENTS Seven hundred and thirteen patients over the age of 18 with severe sepsis or septic shock identified through the Swedish ICU Registry. MAIN OUTCOME MEASURES The primary outcome was 30-day mortality. RESULTS Full compliance was observed in 47.0% of patients, partial compliance in 36.0%, and no compliance in 17.0%. Lack of compliance was independently associated with increased risk of 30-day mortality: the adjusted hazard ratio was 1.86 (95% CI 1.34 to 2.58 P < 0.001) for partial compliance and 2.18 (95% CI 1.34 to 3.40 P < 0.001) for no compliance. The time to first antibiotic administration was not associated with mortality. CONCLUSION Less than half of the patients with severe sepsis and septic shock received antibiotics according to Swedish national guidelines. Full compliance with the guidelines was associated with decreased mortality. The results of this study show that a strict approach to guideline compliance seems to be beneficial: half measures and inadequate doses should be avoided.

Low incidence of antibiotic-resistant bacteria in south-east Sweden: An epidemiologic study on 9268 cases of bloodstream infection

“…Second, the number of patients with multiple comorbidities increased, and since these patients are at greater risk for severe illness they were probably prescribed more antibiotics [43]. Third, modern guidelines recommend higher and more frequent doses of antibiotics which would naturally lead to increased consumption as measured by DDD based on standard doses for the main indication [44][45][46][47][48][49]. This study was not designed to see if the decrease in antibiotic treatment in outpatients correlated with the increase in antibiotic use in hospital, since we did not consider antibiotic use in individual patients.…”

Diagnostic value of metagenomic next-generation sequencing in sepsis and bloodstream infection

“…Early and effective antibiotic course is the key to treating BSI. If the pathogen cannot be identified early in the disease, effective antibiotics will be administered late, which often leads to poor clinical outcomes (Lindberg et al, 2020). In severe sepsis and septic shock, the survival rate of patients decreases by an average of 7.6% every hour of delayed use of effective antibiotics.…”

Clinical Impact of Bloodstream Infections – Characterization, Risk factors and Outcome

“…Antibiotic consumption of narrow-and broad-spectrum antibiotics in hospitals, measured as DDD per 1,000 hospital days, increased by approximately 50% (2008-2016. Several factors could explain this: 1) BSIs per 100,000 hospital days increased by 108% and per 100,000 hospital admissions by 66%, hence the increased use of antibiotics in hospitals; 2) the number of patients with multiple comorbidities increased, and since these patients are at greater risk for severe illness, they were probably prescribed more antibiotics [249]; and 3) modern guidelines recommend higher and more frequent doses of antibiotics which naturally leads to increased consumption as measured by DDD based on standard doses for the main indication [250][251][252][253][254][255]. This study was not designed to see if the decrease in antibiotic use in the community correlated with the increase in antibiotic consumption in hospital since we did not consider antibiotic use in individual patients.…”

“…Multitarget interventions in a "sepsis alarm" programme covering prehospital care, emergency units, and hospital care, were introduced in Sweden at the end of 2018. All patients are triaged for sepsis in the ambulance and at the emergency department using broad sepsis criteria including, but not limited to, the new qSOFA score [252]. Focused treatment and follow-up programmes using algorithms such as the surviving sepsis protocol are applied [4].…”