Delays in appropriate antibiotic therapy for gram-negative bloodstream infections: a multicenter, community hospital study.
Abstract
BACKGROUND: Gram-negative bacterial bloodstream infection (BSI) is a serious condition
with estimated 30% mortality. Clinical outcomes for patients with severe infections
improve when antibiotics are appropriately chosen and given early. The objective of
this study was to estimate the association of prior healthcare exposure on time to
appropriate antibiotic therapy in patients with gram-negative BSI. METHOD: We performed
a multicenter cohort study of adult, hospitalized patients with gram-negative BSI
using time to event analysis in nine community hospitals from 2003-2006. Event time
was defined as the first administration of an antibiotic with in vitro activity against
the infecting organism. Healthcare exposure status was categorized as community-acquired,
healthcare-associated, or hospital-acquired. Time to appropriate therapy among groups
of patients with differing healthcare exposure status was assessed using Kaplan-Meier
analyses and multivariate Cox proportional hazards models. RESULTS: The cohort included
578 patients with gram-negative BSI, including 320 (55%) healthcare-associated, 217
(38%) community-acquired, and 41 (7%) hospital-acquired infections. 529 (92%) patients
received an appropriate antibiotic during their hospitalization. Time to appropriate
therapy was significantly different among the groups of healthcare exposure status
(log-rank p=0.02). Time to first antibiotic administration regardless of drug appropriateness
was not different between groups (p=0.3). The unadjusted hazard ratios (HR) (95% confidence
interval) were 0.80 (0.65-0.98) for healthcare-associated and 0.72 (0.63-0.82) for
hospital-acquired, relative to patients with community-acquired BSI. In multivariable
analysis, interaction was found between the main effect and baseline Charlson comorbidity
index. When Charlson index was 3, adjusted HRs were 0.66 (0.48-0.92) for healthcare-associated
and 0.57 (0.44-0.75) for hospital-acquired, relative to patients with community-acquired
infections. CONCLUSIONS: Patients with healthcare-associated or hospital-acquired
BSI experienced delays in receipt of appropriate antibiotics for gram-negative BSI
compared to patients with community-acquired BSI. This difference was not due to delayed
initiation of antibiotic therapy, but due to the inappropriate choice of antibiotic.
Type
Journal articleSubject
AdolescentAdult
Aged
Aged, 80 and over
Anti-Bacterial Agents
Bacteremia
Cohort Studies
Community-Acquired Infections
Cross Infection
Female
Gram-Negative Bacterial Infections
Hospitals, Community
Humans
Male
Middle Aged
Proportional Hazards Models
Retrospective Studies
Time Factors
Treatment Outcome
Young Adult
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https://hdl.handle.net/10161/13317Published Version (Please cite this version)
10.1371/journal.pone.0076225Publication Info
Moehring, Rebekah W; Sloane, Richard; Chen, Luke F; Smathers, Emily C; Schmader, Kenneth
E; Fowler, Vance G; ... Anderson, Deverick J (2013). Delays in appropriate antibiotic therapy for gram-negative bloodstream infections:
a multicenter, community hospital study. PLoS One, 8(10). pp. e76225. 10.1371/journal.pone.0076225. Retrieved from https://hdl.handle.net/10161/13317.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Deverick John Anderson
Professor of Medicine
Hospital epidemiology, infection control, antibiotic stewardship, multidrug-resistant
organisms, device-related infections, surgical site infections, catheter-associated
bloodstream infections, cost of infections, infections in community hospitals
Luke Francis Chen
Associate Professor of Medicine
Epidemiology, Infection Prevention, Infection Control, Outbreak Investigations, Multi-drug
resistant organisms, multidrug-resistant gram-negative pathogens MDR GNR (e.g. ESBL,
CRE, KPC, NDM-1), C. difficile, MRSA infections health care epidemiology, HIV medicine,
respiratory viral infections, infection control and prevention, health care-associated
infections including bloodstream and surgical-site infections
This author no longer has a Scholars@Duke profile, so the information shown here reflects
their Duke status at the time this item was deposited.
Vance Garrison Fowler Jr.
Florence McAlister Distinguished Professor of Medicine
Determinants of Outcome in Patients with Staphylococcus aureus Bacteremia Antibacterial
ResistancePathogenesis of Bacterial Infections Tropical medicine/International Health
Rebekah Moehring
Associate Professor of Medicine
Kenneth Edwin Schmader
Professor of Medicine
Dr. Schmader’s areas of research include herpes zoster, infections, and vaccines in
older adults. He conducts translational, clinical trials and observational studies
of zoster, influenza, and other infections funded by grants from the National Institute
on Aging (NIA), National Institute of Allergy and Infectious Diseases (NIAID), Centers
for Disease Control (CDC), VA Office of Research and Development, and Industry sources.
He has played a pivotal role in the development o
Daniel John Sexton
Professor Emeritus of Medicine
During the past 8 years my research interests have changed from a focus on tick-borne
disease and endocarditis to a primary focus on healthcare-associated infections (HAIs).
Specifically, I have been interested in HAIs in community hospitals. Using prospective
data collected as part of our surveillance activities in the Duke Infection Control
Outreach Network (DICON), I and my colleagues have focused on these specific areas
of research: • The accuracy and reliability of s
Alphabetical list of authors with Scholars@Duke profiles.

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