Delays in appropriate antibiotic therapy for gram-negative bloodstream infections: a multicenter, community hospital study.
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2013
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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.
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Moehring, Rebekah W, Richard Sloane, Luke F Chen, Emily C Smathers, Kenneth E Schmader, Vance G Fowler, David J Weber, Daniel J Sexton, et al. (2013). Delays in appropriate antibiotic therapy for gram-negative bloodstream infections: a multicenter, community hospital study. PLoS One, 8(10). p. e76225. 10.1371/journal.pone.0076225 Retrieved from https://hdl.handle.net/10161/13317.
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Scholars@Duke
Rebekah Moehring
Kenneth Edwin Schmader
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 of zoster vaccines in older adults. Dr. Schmader also performs research in medications and older adults, focusing on pharmacoepidemiology, optimal drug use and reduction of adverse drug reactions.
He is the Director of the NIA-funded P30 Duke Pepper Older Americans Independence Center, Co-investigator of the NIAID funded Collaborative Influenza Vaccine Innovation Centers (CIVICS) and the CDC Clinical Immunization Safety Assessment (CISA) office at Duke. He serves on the Working Groups for the Herpes Zoster, Influenza, COVID-19, RSV and General Adult Immunization Guidelines for the US Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) and is the American Geriatrics Society liaison to the ACIP.
Daniel John Sexton
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 surveillance definitions used to document and trend rates of HAIs
• Outcomes of HAIs (both financial and clinical) with particular emphasis on bloodstream and surgical site infections
• Trends in HAIs due to pathogens resistant to common antimicrobial agents
• Temporal and geographic variations in the occurrence of pathogens such as methicillin-resistant S. aureus, E coli and Klebsiella pneumonia
• The prevention and control of HAIs with particular emphasis on the potential role of the environment in the transmission of HAIs
As the principal investigator on one of the 5 national epicenter grants funded by the Centers for Disease control I, along with my co-investigators from the Duke and University of North Carolina Division of Infectious Disease, are involved in a 5-year prospective study of the potential benefit of enhanced cleaning methods (such as the use of ultraviolet light emitters) in the prevention of HAIs. This study involves 9 hospitals in North Carolina and Virginia and will include a trial of 4 different cleaning methods utilized sequentially but randomly in these study hospitals over a 28-month time period. Additionally the Duke Epicenter is also undertaking prospective trials investigating the utility and reliability of new (streamlined) definitions of ventilator-associated pneumonia.
Key words that characterize my work: surgical site infections and nosocomial infections.
Deverick John Anderson
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
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