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Physicians accept 80% to 90% pathogen coverage in sepsis treatment

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January 8, 2019

Physicians will accept pathogen coverage of 80% to 90% from their preferred empiric antibiotic regimen when managing patients with mild and severe sepsis, respectively, from bacterial infections, survey results showed.

The survey of internal medicine physicians in Canada also showed that physicians perceived that their preferred empiric antibiotic regimen would cover 90% of the offending pathogens in each clinical scenario of sepsis.

Researchers said the findings could be used to inform clinical guidelines and improve prescribing practices.

According to Alex M. Cressman, MD, MSc, from the University of Toronto and Sunnybrook Health Sciences Center, and colleagues, prescribers must balance “early empiric antibiotic coverage and the antimicrobial stewardship goal of minimizing unnecessary broad-spectrum treatment” when choosing an antibiotic regimen. They suggested a need for treatment thresholds to aid physicians in choosing empiric antibiotic regimens for patients with serious bacterial infections.

“Using a scenario-based survey of general internists and infectious disease specialists across Canada, we characterized physicians’ perceived likelihood of adequate coverage achieved by their preferred empiric antibiotic regimens for patients with mild and severe sepsis,” Cressman and colleagues wrote. “We also identified physicians’ minimum acceptable thresholds of adequate coverage for these patients.”

In the survey, sepsis scenarios were varied by infection source — undifferentiated vs. genitourinary — and severity. According to Cressman and colleagues, participants selected their preferred empiric antibiotic regimen, estimated the likelihood of coverage achieved by that regimen and considered their minimum threshold of coverage for each presented scenario.

Among 238 respondents, 36.6% (n = 87) were residents and 63.4% (n = 151) were attending physicians. For a severe, undifferentiated scenario, the perceived likelihood of antibiotic coverage was 90% (interquartile range [IQR] = 89.5-95.0) and the minimum threshold of coverage was also 90% (IQR = 80-95). For a mild, undifferentiated scenario, it was 89% (IQR = 80-95) and 80% (IQR = 70-89.5). In the case of a severe or mild case of sepsis with a genitourinary source of infection, the perceived likelihood of antibiotic coverage was 91% (IQR = 87.3-95) and 90% (IQR = 81.8-91.3), respectively, whereas the minimum threshold of coverage was 90% (IQR = 80-90) for a severe scenario and 80% (IQR = 71.8-90) for a mild scenario.

“Illness severity and infectious diseases specialty predicted higher thresholds of coverage whereas less clinical experience and lower self-reported prescribing intensity predicted lower thresholds of coverage,” Cressman and colleagues wrote.

“These data may be useful in prioritizing antibiotic regimens in sepsis guidelines, developing decision-support tools and balancing the competing goals of antibiotic coverage and stewardship,” they concluded.

In a related editorial, Marin H. Kollef, MD, professor of medicine in the division of pulmonary and critical care medicine, and Jason P. Burnham, MD, instructor of medicine in the division of infectious diseases, both at Washington University School of Medicine in St. Louis, said the findings offered an insight into the “landscape of attitudes in empiric antibiotic prescribing among Canadian internal medicine and infectious diseases physicians.”

“These findings are of particular interest and relevance given recent recommendations for the treatment of patients with sepsis employing standardized treatment bundles,” they wrote.

According to Kollef and Burnham, treatment bundles can overlook important factors. Specifically, treatment bundles for sepsis tend not to assess antibiotic necessity, dosing strategies and antibiotic duration, and the in vitro activity of the antibiotic regimen. They highlighted the success that rapid molecular diagnostics has had in expediting patient evaluation for sepsis, ensuring effective, early antibiotic therapy and reducing the unnecessary use of broad-spectrum agents.

“Further work is needed to understand their work in a broader context that includes other front-line antibiotic prescribers,” Burnham and Kollef wrote. “Empiric antibiotic prescribing will continue to be a moving target, but with advances in [rapid molecular diagnostics], the ideal scenario of minimizing antibiotic use while maximizing excellent patient outcomes moves closer to realization, including in critically ill patients.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

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