title: Inappropriate antibiotic therapy in Gram-negative sepsis increases hospital length of stay.
abstract: OBJECTIVE
  To describe the impact of initially inappropriate antibiotic therapy on hospital length of stay in Gram-negative severe sepsis and septic shock.
  
  
  METHODS
  Retrospective cohort.
  
  
  METHODS
  Academic urban hospital.
  
  
  METHODS
  Patients with Gram-negative bacteremia (primary or secondary, nosocomial or non-nosocomial) and severe sepsis or septic shock.
  
  
  METHODS
  None.
  
  
  RESULTS
  We defined initially inappropriate antibiotic therapy as occurring when the patient either was not administered an antibiotic within 24 hrs of sepsis onset or was treated with an antibiotic to which the culprit pathogen was resistant in vitro. The cohort included 760 subjects (mean age 59.3 ± 16.3 yrs, mean Acute Physiology and Chronic Health Evaluation II score 23.7 ± 6.7). More than half of infections were nosocomial (55.1%), and Escherichia coli represented the most common pathogen (n = 225). Pseudomonas species were isolated in 17.4% of patients. Nearly one-third of patients (31.3%) received initially inappropriate antibiotic therapy. Patients administered initially inappropriate antibiotic therapy were more likely to have a nosocomial infection, to have underlying cancer or diabetes or both, to require chronic hemodialysis, and to undergo mechanical ventilation. Those administered initially inappropriate antibiotic therapy also faced higher inhospital mortality. The unadjusted median length of stay after sepsis onset in those administered initially inappropriate antibiotic therapy was 11 days compared to 9 days in those treated appropriately (p = .028 by log-rank test). In a Cox model controlling for the multiple confounders noted, initially inappropriate antibiotic therapy independently correlated with continued hospitalization (adjusted hazard ratio 1.19, 95% confidence interval 1.01-1.40, p = .044). Adjusting for these covariates indicated that initially inappropriate antibiotic therapy independently increased the median attributable length of stay by 2 days.
  
  
  CONCLUSIONS
  Initially inappropriate antibiotic therapy occurs in one-third of persons with severe sepsis and septic shock attributable to Gram-negative organisms. Beyond its impact on mortality, initially inappropriate antibiotic therapy is significantly associated with length of stay in this population. Efforts to decrease rates of initially inappropriate antibiotic therapy may serve to improve hospital resource use by leading to shorter overall hospital stays.
authors.affiliation: Washington Hospital Center, Washington, DC, USA.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Shorr
authors.forename: Scott T
authors.initials: ST
authors.lastname: Micek
authors.forename: Emily C
authors.initials: EC
authors.lastname: Welch
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Doherty
authors.forename: Richard M
authors.initials: RM
authors.lastname: Reichley
authors.forename: Marin H
authors.initials: MH
authors.lastname: Kollef
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000175:diagnosis / Q000188:drug therapy*; D015331:Cohort Studies; D024881:Drug Resistance, Bacterial; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000175:diagnosis / Q000188:drug therapy*; D006786:Hospitals, Urban; D006801:Humans; D007902:Length of Stay; D008297:Male; D008508:Medication Errors / Q000706:statistics & numerical data*; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012772:Shock, Septic / Q000175:diagnosis / Q000188:drug therapy*; D017211:Treatment Failure
chemical_list: D000900:Anti-Bacterial Agents