Empirical use of antibiotics in adult intensive care unit: a real-life approach (original) (raw)
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Evaluation of adequacy in empirical antibiotic therapy in a general intensive care unit
2005
Introduction Community-acquired pneumonia remains a common condition worldwide. It is associated with significant morbidity and mortality. The aim of this study was to evaluate conditions that could predict a poor outcome. Design Retrospective analyse of 69 patients admitted to the ICU from 1996 to 2003. Demographic data included age, sex and medical history. Etiologic agents, multiorgan dysfunction, nosocomial infections, SAPS II and PORT scores were recorded for each patient. For statistical analysis we used a t test, chi-square test and Mann-Whitney U test on SPSS ®. A value of P less than 0.05 was considered significant. Results Forty-seven patients were male and 22 patients were female. Mean age was 52 years. Sixty-seven percent had serious pre-morbid conditions including pulmonary disease (34.8%), cardiac problems (36.2%), diabetes (13%) and chronic liver disease (5.8%); 40.6% were smokers, drug abusers or alcohol dependents. Sixtyeight patients required invasive mechanical ventilation. The average length of ventilation was 13.5 days, median 8 days. The mean SAPS II score was 40.14 and the mean PORT score was 141. The mortality rate was 27.5% (SAPS II estimated mortality, 35%). Complications reported were ARDS (40.6%), septic shock (34.8%), acute renal failure (2.9%), cardiac arrest (8.7%) and nosocomial infeccions (46.4%). Mortality rates were higher for previous hepatic (75%) and metabolic (33%) diseases. We found a close association between crude mortality and SAPS II score (P = 0.003) and development of complications (P = 0.0028). Respiratory dysfunction (P = 0.006) and septic shock (P = 0.022) were most significantly related to mortality. No significant differences were founded regarding age, comorbidities, PORT score, etiologic agents, nosocomial infections and length of invasive mechanical ventilation. Conclusions Previous hepatic chronic disease was strictly related to higher mortality as well as isolation of MRSA. ARDS and septic shock predicted a poor outcome. SAPS II score was the best severity indicator of mortality. P2 Closed endotracheal suction system without periodic change versus open endotracheal system
General Medicine: Open Access, 2019
Background: Antibiotics are commonly administered therapies in ICU. There has been a concern over antibiotic misuse recently. ICU is both a victim and a contributor to the ongoing antibiotic misuse problem and a cause of emerging resistance among the pathogens commonly acquired in intensive care units. Because of high mortality associated with sepsis, it is a great challenge for intensive care physicians to select appropriate antibiotic sometimes without any culture and sensitivity. Similarly the time to deescalate also remains a tough call. Selection of appropriate antibiotics empirically has always been a topic of debate among Intensive Care and Infectious Disease practitioners. Objective: The aim of our pilot study was not only to assess the appropriateness of use of antibiotics in our ICU but to help us guide to design a bigger study and structure a stewardship program for ICU. Also to assess the differences among prescription of ICU and Infectious Disease Consultants. Methods: A prospective observational study in King Saud Medical City ICU following antibiotics started and stopped from 6th November 2014 to 23 rd November 2014. Study included 23 adult patients admitted with different etiologies. All 23 patients' records were shared with two alien referees (one was infectious diseases and other was ICU consultant) from other hospital. Prescribers were blinded to the fact that data was being collected for auditing and the referees were blinded to prescribers and to each other's. Results: Total 46 antibiotics were used. 40 among them were started on empirically, 6 were culture based. 31 antibiotics were stopped by ICU. 28 among these 31 antibiotics were empirical. Most of included patients responded to combination or monotherapy. Piperacillin-Tazobactam was the most commonly prescribed antibiotic. No major difference was noted among the choice of intensive care or infectious disease consultant. Conclusion: Empirical antibiotics are vital for patients admitted in ICU. We need to follow hospital's anti-biogram and stewardship programs with prompt de-escalation wherever appropriate.
Infection and Drug Resistance, 2019
Intensive care units (ICUs) are specialized units where patients with critical conditions are admitted for getting specialized and individualized medical treatment. High mortality rates have been observed in ICUs, but the exact reason and factors affecting the mortality rates have not yet been studied in the local population in Pakistan. This study was aimed to determine rational use of antibiotic therapy in ICU patients and its impact on clinical outcomes and mortality rate. This was a retrospective, longitudinal (cohort) study including 100 patients in the ICU of the largest tertiary care hospital of the capital city of Pakistan. It was observed that empiric antibiotic therapy was initiated in 68% of patients, while culture sensitivity test was conducted for only 19% of patients. Thirty-percent of patients developed nosocomial infections and empiric antibiotic therapy was not initiated for those patients (P<0.05). Irrational antibiotic prescribing was observed in 86% of patient...
Infection and Drug Resistance, 2019
Background: Intensive care units (ICUs) are specialized units where patients with critical conditions are admitted for getting specialized and individualized medical treatment. High mortality rates have been observed in ICUs, but the exact reason and factors affecting the mortality rates have not yet been studied in the local population in Pakistan. Aim: This study was aimed to determine rational use of antibiotic therapy in ICU patients and its impact on clinical outcomes and mortality rate. Methods: This was a retrospective, longitudinal (cohort) study including 100 patients in the ICU of the largest tertiary care hospital of the capital city of Pakistan. Results: It was observed that empiric antibiotic therapy was initiated in 68% of patients, while culture sensitivity test was conducted for only 19% of patients. Thirty-percent of patients developed nosocomial infections and empiric antibiotic therapy was not initiated for those patients (P<0.05). Irrational antibiotic prescribing was observed in 86% of patients, and among them, 96.5% mortality was observed (P<0.05). The overall mortality rate was 83%; even higher mortality rates were observed in patients on a ventilator, patients with serious drug-drug interactions, and patients prescribed with irrational antibiotics or nephrotoxic drugs. Adverse clinical outcomes leading to death were observed to be significantly associated (P<0.05) with irrational antibiotic prescribing, nonadjustment of doses of nephrotoxic drugs, use of steroids, and major drug-drug interactions. Conclusion: It was concluded that empiric antibiotic therapy is beneficial in patients and leads to a reduction in the mortality rate. Factors including irrational antibiotic selection, prescribing contraindicated drug combinations, and use of nephrotoxic drugs were associated with high mortality rate and poor clinical outcomes.
ANALYSIS OF ANTIBIOTIC USAGE IN INTENSIVE CARE UNIT (ICU) IN A TERTIARY CARE HOSPITAL
ARTICLE INFO ABSTRACT INTRODUCTION: Over the past decade it has been seen that antibiotic use is rising internationally. Recent reports have shown that there is increased antimicrobial resistance in India. It is a well-known fact that antibiotic misuse has been implicated in clinical, economic and environmental burden; which in turn results in the development of resistance. OBJECTIVE: This surveillance study was done with the objective of describing the antimicrobial prescribing practices in ICU using the WHO prescribing indicators. METHODS: This cross sectional study was conducted in the Medical Records Department of a tertiary care hospital in South India. Hundred prescribing encounters from ICU were collected in a random manner from January 2015 – December 2015. These encounters were analyzed using WHO Antimicrobial Use Indicators. RESULTS: In our study we found that 66% of the patients who was admitted to the hospital received at least one antibiotic. The average number of antimicrobials prescribed per hospitalization was 21.21%. The percentage of generic prescriptions was 61.35%. Only 73.09% of prescribed doses were administered. The average duration of hospital stay was 10.96 days. Antibiotic sensitivity testing was done in 40.90% of the hospitalized patients who were started on antimicrobials. CONCLUSION: The results of this study show that there is a need for strict vigilance of antimicrobial use. Standard treatment guidelines have to be formulated according to the prevalence of diseases and microbial resistance.
Critical Care, 2018
Background: Preparing an antibiotic stewardship program requires detailed information on overall antibiotic use, prescription indication and ecology. However, longitudinal data of this kind are scarce. Computerization of the patient chart has offered the potential to collect complete data of high resolution. To gain insight in our global antibiotic use, we aimed to explore antibiotic prescription in our intensive care unit (ICU) from various angles over a prolonged time period. Methods: We studied all adult patients admitted to Ghent University Hospital ICU from 1 January 2013 until 31 December 2016. Antibiotic prescription data were prospectively merged with diagnostic (suspected focus, severity and probability of infection at the time of prescription, or prophylaxis) and microbiology data by ICU physicians during daily workflow through dedicated software. Definite focus of infection and probability of infection (classified as high/moderate/low) were reassessed by dedicated ICU physicians at patient discharge. Results: During the study period, 8763 patients were admitted and overall antibiotic consumption amounted to 1232 days of therapy (DOT)/1000 patient days. Antibacterial DOT (84% of total DOT) were linked with infection in 80%; the predominant foci were the respiratory tract (49%) and the abdomen (19%). A microbial cause was identified in 56% (3169/5686). Moderate/low probability infections accounted for 42% of antibacterial DOT prescribed for respiratory tract infections; for abdominal infections, this figure was 15%. The median treatment duration of moderate/low probability respiratory infections was 4 days (IQR 3-7). Antifungal DOT (16% of total DOT) were linked with infection in 47% of total antifungal DOT. Antifungal prophylaxis was primarily administered in the surgical ICU (76%), with a median duration of 4 DOT (IQR 2-9). Conclusions: By prospectively combining antibiotic, microbiology and clinical data we were able to construct a longitudinal, multifaceted dataset on antibiotic use and infection diagnosis. A complete overview of this kind may allow the identification of antibiotic prescription patterns that require future antibiotic stewardship attention.
Nepal Mediciti Medical Journal, 2023
BACKGROUND Antibiotics are the most commonly prescribed medicines in intensive care units (ICU). The irrational use of antibiotics leads to the development of multidrug-resistant organisms (MDR). The aim of the study is to determine the bacteriological profile of infections in our ICU and antibiotic prescription practice, before and after the culture results. METHODOLOGY This is a retrospective study conducted in a tertiary-level, 33-bedded ICU in Nepal to evaluate the bacteriological profile and antibiotic prescription practice. The patients who were admitted between a period of 3 months (January 2023 to March 2023) were enrolled. The data variables collected were; patients' details, culture samples sent (blood, urine, endotracheal (ET) aspirate, sputum, cerebrospinal fluid (CSF), wound swab, pleural fluid, ascitic fluid, tissue culture, and peritoneal fluid), gram stain results, culture sensitivity results, empirical antibiotics used, and change in antibiotics following culture results. RESULTS A total of 378 culture samples were obtained from 230 patients. A positive culture report was obtained for 165 (43.65%) of the 378 samples sent. Urine was the most common sample sent for microbiology (28%), followed by blood (25.3%) and sputum (22.75%). The percentage occurrence of gram-negative bacteria was 84%, while that of gram-positive bacteria was 16%. Methicillin-resistant coagulase-negative staphylococcus (MRCONS) was the most common gram-positive organism isolated (46.15%), and Klebsiella pneumoniae was the most common gram-negative organism (38.84%). Cephalosporin was the commonest group of empirical antibiotics used in our ICU, followed by carbapenem. Empirical antibiotic treatment was continued in 108 patients (47%), changed following the culture results in 92 patients (40%), and discontinued in 30 patients (13%). Escalation of antibiotics was done in 78 patients (85%) and de-escalation in 14 patients (15%). CONCLUSION Antimicrobial resistance and the irrational prescription of antibiotics can lead to a global economic burden. Hence, antibiotic stewardship programs are required to reduce the irrational prescribing patterns of antibiotics.
Background: Management of cardiac intensive care unit (ICU) sepsis is complicated by the high incidence of systemic inflammatory response syndrome, which mimics sepsis but without an infective cause. This pilot randomised trial investigated whether or not, in the ICU, 48 hours of broad-spectrum antibiotic treatment was adequate to safely treat suspected sepsis of unknown and unproven origin and also the predictive power of newer biomarkers of sepsis. Objective: The main objective of this pilot study was to provide preliminary data on the likely safety and efficacy of a reduced course of antibiotics for the treatment of ICU infections of unknown origin. Design: A pilot, single-centre, open-label randomised trial. Setting: This study was carried out in the ICU of a tertiary heart and chest hospital. Participants: Patients being treated within the ICU were recruited into the trial if the intensivist was planning to commence antibiotics because of evidence of systemic inflammatory response syndrome and a strong suspicion of infection but there was no actual known source for that infection. Interventions: Broad-spectrum antibiotic treatment administered for 48 hours (experimental) compared with treatment for 7 days (control). Main outcome measures: The primary outcome was a composite outcome of the rate of death or initiation of antibiotic therapy after the completion of the treatment schedule allocated at randomisation. Secondary outcomes included the duration of mechanical ventilation and ICU and hospital stay; the incidence of infection with Clostridium difficile (B. S. Weeks & E. Alcamo) Jones & Bartlett International Publishers, 2008, or methicillin resistant Staphylococcus aureus (MRSA) (B. S. Weeks & E. Alcamo) Jones & Bartlett International Publishers, 2008; resource utilisation and costs associated with each of the two pilot arms; the ratio of patients screened to patients eligible to patients randomised; the incidence of crossover between groups; and the significance of newer biomarkers for sepsis for predicting patients’ need for further antibiotics. Results: A total of 46 patients were recruited into the trial, with 23 randomised to each group. There was no significant difference between the two groups in terms of the composite primary outcome measure. The risk difference was 0.12 [95% confidence interval (CI) 0.11 to 0.13; p = 0.3]. In the 2-day group, four patients (17.4%) required further antibiotics compared with three (13%) in the 7-day group. Four patients died within the trial period and the deaths were not trial related. Patients who died during the trial period received no additional antibiotics in excess of their trial allocation. There were no documented incidences of MRSA or C. difficile infection in either group. No significant differences in adverse events were observed between the groups. Key economic findings were mean antibiotic costs per patient of £168.97 for the 2-day group and £375.86 for the 7-day group. The potential per annum cost saving for the ICU of 2-day treatment was estimated to range from £108,140 to £126,060. Patient screening was considered the biggest barrier to recruitment. There was no crossover between the two randomised groups. Data verification ascertained > 98% accuracy in data collection. Baseline procalcitonin was found to be predictive of the composite outcome (death and needing further antibiotics) (odds ratio 1.79, 95% CI 1.20 to 2.67; p = 0.005). Analysis of baseline procalcitonin also indicated a trend towards it being a predictor of restarting antibiotics, with an odds ratio of 1.45 (95% CI 1.04 to 2.02; p = 0.01). Conclusions: Data from this pilot study suggest that there could be significant benefits of reducing broad-spectrum antibiotic use in the ICU without it undermining patient safety, with a potential cost saving in our unit of over £100,000 per year. Evidence from this pilot trial is not definitive but warrants further investigation using a large randomised controlled trial. Trial registration: Current Controlled Trials ISRCTN82694288. Funding: This project was funded by the NIHR Health Technology Assessment programme
Dicle Tıp Dergisi, 2019
Objective: Aim of study is to determine which antibiotic is started empirically in the ICU and to investigate whether the antibiotic started according to culture result was changed or not and the effect of this change on mortality, and to investigate the relationship between mortality and infection by determining whether enteral and parenterally fed patients have attained sufficient calorie level. Method: After the approval of the local ethics committee, the files of 476 patients hospitalized in our hospital were retrospectively reviewed. A total of 159 patients over 18 years of age who received mechanical ventilation therapy for at least 3 days were included in the study. Blood, urine and tracheal aspirate culture were determined. It was recorded whether antibiotics had changed according to the culture result. Nutritional patterns, number of feeding days and basal caloric need were determined. It was investigated whether basal calorie need was met on 1, 3 and 5 days. Factors affecting mortality were investigated. Results: Antibiotic exchange was significantly higher in the patients who died (P = 0.002). Mortality was higher in patients who were unable to reach the target calorie (P = 0.01). Empirical changes in antibiotics (r: 0.174, P = 0.028), and culture positivity (r: 0.177, P = 0.026) were associated with mortality (r: 0.195, P = 0.014). In the subgroup analysis, reproduction in tracheal aspirate culture was an important factor affecting mortality (r: 0.211 P: 0.008). Conclusions: The number of days of hospitalization, antibiotic change, culture positivity and inability to reach the target calories in nutrition are associated with mortality in the intensive care unit.