Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-28T05:16:19.412Z Has data issue: false hasContentIssue false
  • English
  • Français

A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study

Published online by Cambridge University Press:  11 July 2017

John Burston ,
Suman Adhikari ,
Andrew Hayen ,
Heather Doolan ,
Melissa L. Kelly ,
Kathy Fu ,
Tomas O. Jensen  and
Pamela Konecny
John Burston
Affiliation:
Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
Suman Adhikari
Affiliation:
St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia Pharmacy Department, St George Hospital, Sydney, Australia
Andrew Hayen
Affiliation:
School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia Faculty of Health, University of Technology, Sydney, Australia
Heather Doolan
Affiliation:
St George Hospital Nursing Administration, Sydney, Australia
Melissa L. Kelly
Affiliation:
Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
Kathy Fu
Affiliation:
Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
Tomas O. Jensen
Affiliation:
Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
Pamela Konecny*
Affiliation:
Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia St George and Sutherland Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
*
Address correspondence to Pamela Konecny, St George Hospital, Department of Infectious Diseases, Immunology & Sexual Health, 2 South St, Kogarah, Sydney, NSW 2217, Australia (pam.konecny@health.nsw.gov.au).
Get access Rights & Permissions [Opens in a new window]

Abstract

OBJECTIVE

To evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management.

DESIGN

Interventional, nonrandomized, controlled study.

SETTING

Tertiary-care referral hospital, Sydney, Australia.

PATIENTS

Consecutive, adult, non–intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015.

INTERVENTION

All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger.

RESULTS

In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04–1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant.

CONCLUSION

Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes.

Infect Control Hosp Epidemiol 2017;38:1032–1038

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 9 , September 2017 , pp. 1032 - 1038
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Cohen, J, Vincent, J-L, Adhikari, NKJ, et al. Sepsis: a roadmap for future research. Lancet Infect Dis 2015;15:581–614.CrossRefGoogle ScholarPubMed
2. Vincent, J, Marshall, JC, Silvio, AN, et al. Assessment of the worldwide burden of critical illness: the Intensive Care Over Nations (ICON) audit. Lancet Respir Med 2014;2:380–386.CrossRefGoogle ScholarPubMed
3. Kumar, A, Roberts, D, Wood, KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589–1596.CrossRefGoogle ScholarPubMed
4. Sterling, SA, Miller, WR, Pryor, J, et al. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock: a systematic review and meta-analysis. Crit Care Med 2015;43:1907–1905.CrossRefGoogle ScholarPubMed
5. Ryoo, SM, Kim, WY, Sohn, CH, et al. Prognostic value of timing of antibiotic administration in patients with septic shock treated with early quantitative resuscitation. Am J Med Sci 2015;349:328–333.CrossRefGoogle ScholarPubMed
6. Dellinger, RP, Levy, MM, Rhodes, A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637.CrossRefGoogle ScholarPubMed
7. Sepsis toolkit: inpatient program implementation guide. Clinical Excellence Commission website. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/276067/Sepsis_Toolkit_inpatient-full.pdf. Published 2014. Accessed June 1, 2017.Google Scholar
8. Davey, P, Brown, E, Charani, E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;4. doi: 10.1002/14651858.CrossRefGoogle Scholar
9. Taylor, MJ, McNicholas, C, Nicolay, C, et al. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Quality & Safety 2013:1–9.Google ScholarPubMed
10. Antimicrobial prescribing practice in Australian hospitals: results of the 2014 National Antimicrobial Prescribing Survey. Australian Commission on Safety and Quality in Health Care website. https://www.safetyandquality.gov.au/wp-content/uploads/2016/03/Antimicrobial-prescribing-practice-in-Aust-hospitals-NAPS-2014-Results.pdf. Published 2016. Accessed June 1, 2017.Google Scholar
11. Therapeutic Guidelines Limited website. http://www.tg.org.au. Published 2015. Accessed June 1, 2017.Google Scholar
12. Pulcini, C, Botelho-Nevers, E, Dyar, OJ, Harbarth, S. The impact of infectious disease specialists on antibiotic prescribing in hospitals. Clin Microbiol Infect 2014;20:963–972.CrossRefGoogle ScholarPubMed
13. Butt, AA, Al Kaabi, N, Saifuddin, M, et al. Impact of infectious diseases team consultation on antimicrobial use, length of stay and mortality. Am J Med Sci 2015;350:191–194.CrossRefGoogle ScholarPubMed
14. Fariñas, M, Saravia, G, Calvo-Montes, J, et al. Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients. BMC Infect Dis 2012;12:292.CrossRefGoogle ScholarPubMed
15. Filice, GA, Drekonja, DM, Thurn, JR, Hamann, GM, Masoud, BT, Johnson, JR. Diagnostic errors that lead to inappropriate antimicrobial use. Infect Control Hosp Epidemiol 2015;36:949–956.CrossRefGoogle ScholarPubMed
16. Bond, SE, Chubaty, AJ, Adhikari, S, et al. Outcomes of multisite antimicrobial stewardship program implementation with a shared clinical decision support system. J Antimicrob Chemother 2017. doi: 10.1093/jac/dkx080.CrossRefGoogle ScholarPubMed
17. Wisom, A, Eaton, V, Gordon, D, et al. INITIAT-E.D.: impact of timing of initiation of antibiotic therapy on mortality of patients presenting to an emergency department with sepsis. Emergency Medicine Australasia 2015;27:196–207.CrossRefGoogle Scholar
18. Schuts, EC, Hulscher, MEJL, Mouton, JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016;16:847–856.CrossRefGoogle ScholarPubMed
19. Burrell, AR, McLaws, M-L, Fullick, M, et al. Sepsis kills: early intervention saves lives. Med J Aust 2016;204:1.e1–e7.CrossRefGoogle ScholarPubMed
20. Kaukonen, K, Bailey, M, Suzuki, S, et al. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA 2014;311:1308–1316.CrossRefGoogle ScholarPubMed
21. Yokota, PK, Alexandre, RM, Marines, DV, et al. Impact of appropriate antimicrobial therapy for patients with severe sepsis and septic shock: a quality improvement study. PLoSOne 2014;9:e104475.CrossRefGoogle ScholarPubMed
22. Fremantle, N, Ray, D, McNulty, D, et al. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351:h4596.CrossRefGoogle Scholar
23. Singer, M, Deutschman, CS, Warren Seymour, C, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801–810.CrossRefGoogle ScholarPubMed
24. Sepsis kills. Sepsis tools. Clinical Excellence Commission website. http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0005/299417/adult-antibiotic-guideline-severe-sepsis-septic-shock-sept2016.pdf. Published 2016. Accessed June 1, 2017.Google Scholar