Stratification of the Impact of Inappropriate Empirical Antimicrobial Therapy for Gram-Negative Bloodstream Infections by Predicted Prognosis

Abstract

dThe bloodstream infection mortality risk score (BSIMRS) predicts the outcome of patients with Gram-negative bloodstream infections (BSI) with high discrimination. This retrospective cohort study examined the impact of inappropriate antimicrobial therapy on mortality in adult patients with Gram-negative BSI admitted to Palmetto Health Hospitals in Columbia, SC, USA, from 1 January 2011 to 31 December 2012 after stratification by predicted prognosis at initial presentation using BSIMRS. A multivariate Cox regression model was used to identify independent risk factors for 28-day mortality overall and within each predefined BSIMRS category (<5, 5 to 9, and >10). Relative risk reduction (RRR), absolute risk reduction (ARR), and number needed to treat (NNT) were calculated from a predictive logistic regression model of mortality. Overall, 390 unique patients with first episodes of Gram-negative BSI were identified. The median age was 66 years, and 229 (59%) were women. There was significant association between inappropriate antimicrobial therapy and mortality in patients with BSIMRS of 5 to 9 (adjusted hazard ratio

Impact of Penicillin Allergy on Empirical Carbapenem Use in Gram‐Negative Bloodstream Infections: An Antimicrobial Stewardship Opportunity

“…26 This approach improves patient outcomes, reduces adverse events, and reduces potential development of antimicrobial resistance. 27,28 In the current study, a bundle of antimicrobial stewardship interventions was successful in reducing empirical carbapenem use for community-onset gram-negative BSI. Moreover, when carbapenems were started in patients with penicillin allergy, antimicrobial stewardship interventions reduced the time to deescalation off carbapenems by more than 50%.…”

“…Antimicrobial stewardship interventions are essential for optimization of empirical antimicrobial therapy in patients with serious infections, such as gram‐negative BSI, while reducing unnecessary use of broad‐spectrum agents . This approach improves patient outcomes, reduces adverse events, and reduces potential development of antimicrobial resistance . In the current study, a bundle of antimicrobial stewardship interventions was successful in reducing empirical carbapenem use for community‐onset gram‐negative BSI.…”

Direct detection ofmecA,blaSHV, blaCTX-M,blaTEMandblaOXAgenes from positive blood culture bottles by multiplex-touchdown PCR assay

“…; Cain et al . ). Therefore, rapid identification of resistant pathogens in the laboratory is important to guide treatment of the patient.…”

“…The timely administration of appropriate antimicrobial therapy for resistant pathogens was independently associated with a decline in the mortality of patients with severe sepsis and septic shock (Yokota et al 2014;Cain et al 2015). Therefore, rapid identification of resistant pathogens in the laboratory is important to guide treatment of the patient.…”

Mortality and Length of Stay in Patients with Bloodstream Infections Due to Drug-Susceptible Versus Drug-Resistant Gram-Negative Bacteria

“…Despite several studies that address mortality and length of hospital stay contrasted with inappropriate therapy [12,13], few studies either focused on monomicrobial resistance like Acinetobacter and Pseudomonas as a cause of inappropriate empiric therapy and mortality, while another study invited to look at resistance as a major part of inappropriate therapy [14,15,9]. Our study directly asses resistance patterns according to an international experts proposal classification for the definition of XDR and MDR gram-negative bacteria (excluding the pan drug-resistant bacteria PDRGNB for being not present in our patients) and their impact on mortality and length of ICU and hospital stay [3,7] In the quest to analyze our data based on the unique resistance patterns in relation to the outcomes, we tried our best to adjust for several confounders and lurking variables like age, gender, SOFA and APACHE II scores, initial admission diagnoses, comorbidities, the infecting bacterial species, other classified resistance patterns like ESBL, CRE, and types of bacteria based on lactose fermentation.…”