title: Predictive value of prior colonization and antibiotic use for third-generation cephalosporin-resistant enterobacteriaceae bacteremia in patients with sepsis.
abstract: BACKGROUND
  To prevent inappropriate empiric antibiotic treatment in patients with bacteremia caused by third-generation cephalosporin (3GC)-resistant Enterobacteriaceae (3GC-R EB), Dutch guidelines recommend β-lactam and aminoglycoside combination therapy or carbapenem monotherapy in patients with prior 3GC-R EB colonization and/or recent cephalosporin or fluoroquinolone usage. Positive predictive values (PPVs) of these determinants are unknown.
  
  
  METHODS
  We retrospectively studied patients with a clinical infection in whom blood cultures were obtained and empiric therapy with broad-spectrum β-lactams and/or aminoglycosides and/or fluoroquinolones was started. We determined the PPVs of prior colonization and antibiotic use for 3GC-R EB bacteremia, and the consequences of guideline adherence on appropriateness of empiric treatment.
  
  
  RESULTS
  Of 9422 episodes, 773 (8.2%) were EB bacteremias and 64 (0.7%) were caused by 3GC-R EB. For bacteremia caused by 3GC-R EB, PPVs of prior colonization with 3GC-R EB (90-day window) and prior usage of cephalosporins or fluoroquinolones (30-day window) were 7.4% and 1.3%, respectively, and PPV was 1.8% for the presence of any of these predictors. Adherence to Dutch sepsis guideline recommendations was 27%. Of bacteremia episodes caused by 3GC-R and 3GC-sensitive EB, 56% and 94%, respectively, were initially treated with appropriate antibiotics. Full adherence to guideline recommendations would hardly augment proportions of appropriate therapy, but could considerably increase carbapenem use.
  
  
  CONCLUSIONS
  In patients receiving empiric treatment for sepsis, prior colonization with 3GC-R EB and prior antibiotic use have low PPV for infections caused by 3GC-R EB. Strict guideline adherence would unnecessarily stimulate broad-spectrum antibiotic use.
authors.affiliation: Julius Center for Health Sciences and Primary Care.
authors.forename: Wouter C
authors.initials: WC
authors.lastname: Rottier
authors.affiliation: Julius Center for Health Sciences and Primary Care.
authors.forename: Yara R P
authors.initials: YR
authors.lastname: Bamberg
authors.affiliation: Central Laboratory for Bacteriology and Serology.
authors.forename: J Wendelien
authors.initials: JW
authors.lastname: Dorigo-Zetsma
authors.affiliation: Department of Clinical Pharmacy, Tergooi Hospitals, Hilversum, The Netherlands.
authors.forename: Paul D
authors.initials: PD
authors.lastname: van der Linden
authors.affiliation: Julius Center for Health Sciences and Primary Care.
authors.forename: Heidi S M
authors.initials: HS
authors.lastname: Ammerlaan
authors.affiliation: Julius Center for Health Sciences and Primary Care Department of Medical Microbiology, University Medical Center Utrecht.
authors.forename: Marc J M
authors.initials: MJ
authors.lastname: Bonten
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D002511:Cephalosporins / Q000494:pharmacology*; D004363:Drug Utilization; D004755:Enterobacteriaceae / Q000187:drug effects* / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D004812:Epidemiologic Methods; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018805:Sepsis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D055815:Young Adult; D018440:beta-Lactam Resistance
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins
keywords: carbapenems; empiric antibiotic therapy; extended-spectrum β-lactamases; inappropriate antibiotic therapy; risk factors