title: Gram-negative bacteraemia in non-ICU patients: factors associated with inadequate antibiotic therapy and impact on outcomes.
abstract: BACKGROUND
  A considerable number of gram-negative bacteraemias occur outside intensive care units (ICUs). Inadequate antibiotic therapy in ICUs has been associated with adverse outcomes; however, there are no prospective studies in non-ICU patients.
  
  
  METHODS
  A 6 month (1 August 2006-31 January 2007), prospective cohort study of non-ICU patients with gram-negative bacteraemia in a tertiary-care hospital was performed. Inadequate empirical antibiotic therapy was defined as no antibiotic or starting a non-susceptible antibiotic within 24 h after the initial positive blood culture.
  
  
  RESULTS
  Two hundred and fifty non-ICU patients had gram-negative bacteraemia. The mean age was 56.4 (+/-16.1) years. The predominant bacteria in monomicrobial infections were Escherichia coli (24%), Klebsiella pneumoniae (18%) and Pseudomonas aeruginosa (8%). Sixty-one (24%) patients had polymicrobial bacteraemia. Seventy patients (28%) required ICU transfer and 35 (14%) died. Seventy-nine (31.6%) received inadequate empirical antibiotic therapy. These patients were more likely to have a hospital-acquired infection [odds ratio (OR) = 1.99, 95% confidence interval (CI) = 1.11-3.56, P = 0.02] and less likely to have E. coli monomicrobial bacteraemia [OR 0.40 (95% CI 0.19-0.86), P = 0.02]. There were no differences in occurrence of sepsis [72 (91.1%) patients with inadequate versus 159 (93.0%) with adequate therapy; P = 0.6], ICU transfer [20 (25.3%) versus 50 (29.2%); P = 0.5], post-bacteraemia length of stay (median = 6.8 versus 6.1 days; P = 0.09) or death [11 (13.9%) versus 24 (14.0%); P = 1.0].
  
  
  CONCLUSIONS
  Nearly one-third of the non-ICU patients with gram-negative bacteraemia received inadequate empirical antibiotic therapy. There was no difference in adverse outcomes between patients receiving inadequate or adequate therapy in this study.
authors.affiliation: Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA. jmarscha@im.wustl.edu
authors.forename: Jonas
authors.initials: J
authors.lastname: Marschall
authors.forename: Denis
authors.initials: D
authors.lastname: Agniel
authors.forename: Victoria J
authors.initials: VJ
authors.lastname: Fraser
authors.forename: Joshua
authors.initials: J
authors.lastname: Doherty
authors.forename: David K
authors.initials: DK
authors.lastname: Warren
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D016470:Bacteremia / Q000150:complications / Q000188:drug therapy* / Q000382:microbiology* / Q000401:mortality; D015331:Cohort Studies; D003428:Cross Infection / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D004926:Escherichia coli / Q000187:drug effects / Q000302:isolation & purification; D005260:Female; D006090:Gram-Negative Bacteria / Q000187:drug effects* / Q000302:isolation & purification; D016905:Gram-Negative Bacterial Infections / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D006761:Hospitals; D006801:Humans; D007297:Inpatients; D007711:Klebsiella pneumoniae / Q000187:drug effects / Q000302:isolation & purification; D007902:Length of Stay; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011446:Prospective Studies; D011550:Pseudomonas aeruginosa / Q000187:drug effects / Q000302:isolation & purification; D018805:Sepsis / Q000382:microbiology; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents