Impact of appropriate antimicrobial therapy for patients with severe sepsis and septic shock--a quality improvement study.
BACKGROUND
There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes.


METHODS
This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock.


RESULTS
A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023).


CONCLUSIONS
The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.
Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Paula K O
PK
Yokota
Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Alexandre R
AR
Marra
Laboratory of Microbiology, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Marines D V
MD
Martino
Statistics Department, Instituto Israelita de Ensino e Pesquisa (IIEP), Hospital Israelita Albert Einstein, São Paulo, Brazil.
Elivane S
ES
Victor
Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Marcelino S
MS
Durão
Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America.
Michael B
MB
Edmond
Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Oscar F P
OF
dos Santos
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D004927:Escherichia coli Infections / Q000188:drug therapy* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D012189:Retrospective Studies; D018805:Sepsis / Q000188:drug therapy* / Q000401:mortality; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000401:mortality; D013290:Streptococcal Infections / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome
D000890:Anti-Infective Agents