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A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study

  • John Burston (a1) (a2), Suman Adhikari (a2) (a3), Andrew Hayen (a4) (a5), Heather Doolan (a6), Melissa L. Kelly (a1) (a2), Kathy Fu (a1) (a2), Tomas O. Jensen (a1) (a2) and Pamela Konecny (a1) (a2)...
Abstract
OBJECTIVE

To evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management.

DESIGN

Interventional, nonrandomized, controlled study.

SETTING

Tertiary-care referral hospital, Sydney, Australia.

PATIENTS

Consecutive, adult, non–intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015.

INTERVENTION

All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger.

RESULTS

In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04–1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant.

CONCLUSION

Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes.

Infect Control Hosp Epidemiol 2017;38:1032–1038

Copyright
Corresponding author
Address correspondence to Pamela Konecny, St George Hospital, Department of Infectious Diseases, Immunology & Sexual Health, 2 South St, Kogarah, Sydney, NSW 2217, Australia (pam.konecny@health.nsw.gov.au).
Linked references
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This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1. J Cohen , J-L Vincent , NKJ Adhikari , et al. Sepsis: a roadmap for future research. Lancet Infect Dis 2015;15:581614.

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6. RP Dellinger , MM Levy , A Rhodes , et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580637.

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15. GA Filice , DM Drekonja , JR Thurn , GM Hamann , BT Masoud , JR Johnson . Diagnostic errors that lead to inappropriate antimicrobial use. Infect Control Hosp Epidemiol 2015;36:949956.

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19. AR Burrell , M-L McLaws , M Fullick , et al. Sepsis kills: early intervention saves lives. Med J Aust 2016;204:1.e1–e7.

23. M Singer , CS Deutschman , C Warren Seymour , et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801810.

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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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