In the Journals

Inappropriate antibiotics, overdiagnosis may hinder sepsis treatment pathway

Overdiagnosis of sepsis and delayed optimization of antibiotics may reduce sepsis pathway effectiveness, according to researchers in Australia.

“Although early antibiotic therapy is likely to reduce mortality in severe sepsis, recent debate has focused on the importance of antibiotic appropriateness in addition to timing,” John Burston, MBBS, FRACP, of the department of infectious diseases, immunology and sexual health at St. George Hospital, Sydney, and colleagues wrote.

Burston and colleagues wrote that a statewide clinical sepsis pathway prescribed for emergency departments and inpatient wards in New South Wales promoted such practices as performing blood cultures, intravenous fluid resuscitation, measuring serum lactate levels and administering antibiotics within 60 minutes of diagnosing sepsis.

“Preliminary evaluation of our hospital sepsis pathway implementation revealed that half of the patients who triggered the pathway did not have sepsis and were frequently prescribed prolonged broad-spectrum antibiotic courses requiring infectious disease antimicrobial stewardship intervention,” the researchers wrote.

Burston and colleagues performed an interventional, nonrandomized controlled study at a tertiary care hospital in Sydney, evaluating 158 patients who triggered the facility’s sepsis pathway. All patients were reviewed within 24 hours of diagnosis. The researchers’ main outcome was appropriateness of antibiotics at 48 hours after triggering the sepsis pathway. Patients who were not followed by an infectious disease fellow were considered controls and continued under standard care (n = 52).

Ninety-one patients (58%) had sepsis, 15 of whom (9.%) had severe sepsis, Burston and colleagues reported. Initial antibiotic prescriptions were appropriate in 80 of 152 patients who could be assessed (53%), and inappropriate in 72 (47%). The researchers wrote that infectious disease fellows’ recommendations were followed nearly all of the time in the intervention arm (93%), with antibiotics de-escalated in 53% of cases.

Intervention from an infectious disease fellow improved the appropriateness of antibiotics by 24% at the 48-hour mark, Burston and colleagues wrote (adjusted risk ratio, 1.24; 95% CI, 1.04-1.47). Agreement on appropriateness of therapy was 95%, as decided among blinded infectious disease staff members. There were no significant differences in mortality between the intervention and control groups (13% vs. 17%), or median length of stay (13 days vs. 17.5 days).

“Lack of sepsis diagnostic specificity hinders clinical sepsis pathway implementation and may drive inappropriate antibiotic use,” Burston and colleagues wrote. “Hospitals implementing sepsis pathwas should evaluate their diagnostic specificity and patients’ antibiotic exposure and consider how [antimicrobial stewardship] may optimize these. Larger prospective studies are needed to validate these findings and evaluate clinical outcomes.” – by Andy Polhamus

Disclosure: The researchers report no relevant financial disclosures.

Intervention from an infectious disease fellow improved the appropriateness of antibiotics by 24% 48 hours after triggering the sepsis pathway.

Overdiagnosis of sepsis and delayed optimization of antibiotics may reduce sepsis pathway effectiveness, according to researchers in Australia.

“Although early antibiotic therapy is likely to reduce mortality in severe sepsis, recent debate has focused on the importance of antibiotic appropriateness in addition to timing,” John Burston, MBBS, FRACP, of the department of infectious diseases, immunology and sexual health at St. George Hospital, Sydney, and colleagues wrote.

Burston and colleagues wrote that a statewide clinical sepsis pathway prescribed for emergency departments and inpatient wards in New South Wales promoted such practices as performing blood cultures, intravenous fluid resuscitation, measuring serum lactate levels and administering antibiotics within 60 minutes of diagnosing sepsis.

“Preliminary evaluation of our hospital sepsis pathway implementation revealed that half of the patients who triggered the pathway did not have sepsis and were frequently prescribed prolonged broad-spectrum antibiotic courses requiring infectious disease antimicrobial stewardship intervention,” the researchers wrote.

Burston and colleagues performed an interventional, nonrandomized controlled study at a tertiary care hospital in Sydney, evaluating 158 patients who triggered the facility’s sepsis pathway. All patients were reviewed within 24 hours of diagnosis. The researchers’ main outcome was appropriateness of antibiotics at 48 hours after triggering the sepsis pathway. Patients who were not followed by an infectious disease fellow were considered controls and continued under standard care (n = 52).

Ninety-one patients (58%) had sepsis, 15 of whom (9.%) had severe sepsis, Burston and colleagues reported. Initial antibiotic prescriptions were appropriate in 80 of 152 patients who could be assessed (53%), and inappropriate in 72 (47%). The researchers wrote that infectious disease fellows’ recommendations were followed nearly all of the time in the intervention arm (93%), with antibiotics de-escalated in 53% of cases.

Intervention from an infectious disease fellow improved the appropriateness of antibiotics by 24% at the 48-hour mark, Burston and colleagues wrote (adjusted risk ratio, 1.24; 95% CI, 1.04-1.47). Agreement on appropriateness of therapy was 95%, as decided among blinded infectious disease staff members. There were no significant differences in mortality between the intervention and control groups (13% vs. 17%), or median length of stay (13 days vs. 17.5 days).

“Lack of sepsis diagnostic specificity hinders clinical sepsis pathway implementation and may drive inappropriate antibiotic use,” Burston and colleagues wrote. “Hospitals implementing sepsis pathwas should evaluate their diagnostic specificity and patients’ antibiotic exposure and consider how [antimicrobial stewardship] may optimize these. Larger prospective studies are needed to validate these findings and evaluate clinical outcomes.” – by Andy Polhamus

Disclosure: The researchers report no relevant financial disclosures.

Intervention from an infectious disease fellow improved the appropriateness of antibiotics by 24% 48 hours after triggering the sepsis pathway.