title: Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study.
abstract: BACKGROUND
  Antimicrobial treatment in critically ill patients can either be started as soon as infection is suspected or after objective data confirm an infection. We postulated that delaying antimicrobial treatment of patients with suspected infections in the surgical intensive care unit (SICU) until objective evidence of infection had been obtained would not worsen patient mortality.
  
  
  METHODS
  We did a 2-year, quasi-experimental, before and after observational cohort study of patients aged 18 years or older who were admitted to the SICU of the University of Virginia (Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was used: patients suspected of having an infection on the basis of clinical grounds had blood cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a conservative strategy was used, with antimicrobial treatment started only after objective findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses were by intention to treat.
  
  
  RESULTS
  Admissions to the SICU for the first and second years were 762 and 721, respectively, with 101 patients with SICU-acquired infections during the aggressive year and 100 patients during the conservative year. Compared with the aggressive approach, the conservative approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%]; p=0·015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0·0095), and a shorter mean duration of therapy (12·5 days [SD 10·7] vs 17·7 [28·1]; p=0·0080). After adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation (APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the aggressive therapy group compared with the conservative therapy group was 2·5 (95% CI 1·5-4·0).
  
  
  CONCLUSIONS
  Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected SICU-acquired infections does not worsen mortality and might be associated with better outcomes and use of antimicrobial drugs.
  
  
  BACKGROUND
  National Institutes of Health.
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, VA, USA.
authors.forename: Tjasa
authors.initials: T
authors.lastname: Hranjec
authors.forename: Laura H
authors.initials: LH
authors.lastname: Rosenberger
authors.forename: Brian
authors.initials: B
authors.lastname: Swenson
authors.forename: Rosemarie
authors.initials: R
authors.lastname: Metzger
authors.forename: Tanya R
authors.initials: TR
authors.lastname: Flohr
authors.forename: Amani D
authors.initials: AD
authors.lastname: Politano
authors.forename: Lin M
authors.initials: LM
authors.lastname: Riccio
authors.forename: Kimberley A
authors.initials: KA
authors.lastname: Popovsky
authors.forename: Robert G
authors.initials: RG
authors.lastname: Sawyer
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D000890:Anti-Infective Agents / Q000008:administration & dosage*; D016001:Confidence Intervals; D003422:Critical Care / Q000706:statistics & numerical data*; D016638:Critical Illness; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D013997:Time Factors
chemical_list: D000890:Anti-Infective Agents