Chest
Volume 118, Issue 1, July 2000, Pages 146-155
Journal home page for Chest

Clinical Investigations in Critical Care
The Influence of Inadequate Antimicrobial Treatment of Bloodstream Infections on Patient Outcomes in the ICU Setting

https://doi.org/10.1378/chest.118.1.146Get rights and content

Study objective

To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission.

Setting

A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital.

Patients

Between July 1997 and July 1999, 492 patients were prospectively evaluated.

Intervention

Prospective patient surveillance and data collection.

Results

One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2.18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment.

Conclusions

The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.

Section snippets

Study Location and Patients

The study was conducted at a university-affiliated urban teaching hospital: Barnes-Jewish Hospital (1,200 beds), in St. Louis, MO. During a 2-year period (July 1997 to July 1999), all patients admitted to the medical ICU (19 beds) and surgical ICU (18 beds) were potentially eligible for this investigation. The medical and surgical ICUs are closed units with dedicated multidisciplinary health-care teams led by board-certified critical care specialists directing patient medical care. The

Patients

A total of 4,913 consecutive eligible patients were prospectively evaluated in the ICU. Among these, 492 patients (10.0%) were identified as having a bloodstream infection and were included in the study cohort (Table 1). The mean age of the patients was 57.8 ± 17.6 years (range, 15 to 102 years), and the mean APACHE II score was 23.4 ± 8.7 (range, 0 to 51). The mean APACHE II score of patients without bloodstream infection from these two ICUs during the same time period (n = 3,299) was 16.5 ±

Discussion

Our study demonstrated that critically ill patients with a bloodstream infection who received inadequate antimicrobial treatment were significantly more likely to die during their hospitalization compared with similar patients with bloodstream infections receiving adequate antimicrobial treatment. We also identified potential risk factors for the administration of inadequate antimicrobial treatment. These risk factors included the presence of a bloodstream infection caused by Candida species,

References (48)

  • VidalF et al.

    Epidemiology and outcome of Pseudomonas aeruginosa bacteremia, with special emphasis on the influence of antibiotic treatment: analysis of 189 episodes.

    Arch Intern Med

    (1996)
  • Caballero-GranadoFJ et al.

    Comparative study of bacteremias caused by Enterococcus spp. with and without high-level resistance to gentamicin.

    J Clin Microbiol

    (1998)
  • BryanCS et al.

    Analysis of 1186 episodes of Gram-negative bacteremia in non-university hospitals: the effects of antimicrobial therapy.

    Rev Infect Dis

    (1983)
  • ChowJW et al.

    Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy.

    Ann Intern Med

    (1991)
  • MainousMR et al.

    Enterococcal bacteremia in the surgical intensive care unit: does vancomycin resistance affect mortality?

    Arch Surg

    (1997)
  • LucasGM et al.

    Vancomycin-resistant and vancomycin-susceptible enterococcal bacteremia: comparison of clinical features and outcomes.

    Clin Infect Dis

    (1998)
  • SteinbergJP et al.

    Nosocomial and community-acquired Staphylococcus aureus bacteremias from 1980 to 1993: impact of intravascular devices and methicillin resistance.

    Clin Infect Dis

    (1996)
  • AscarJF.

    Consequences of bacterial resistance to antibiotics in medical practice.

    Clin Infect Dis

    (1997)
  • CohenML.

    Epidemiology of drug resistance: implications for a post-antimicrobial era.

    Science

    (1992)
  • Impacts of antibiotic-resistant bacteria: thanks to penicillin, he will come home! Washington, DC: Office of Technology...
  • RubinRJ et al.

    The economic impact of Staphylococcus aureus infection in New York City hospitals.

    Emerg Infect Dis

    (1999)
  • CarmeliY et al.

    Health and economic outcomes of antibiotic resistance in Pseudomonas aeruginosa.

    Arch Intern Med

    (1999)
  • HolembergSD et al.

    Health and economic impact of antimicrobial resistance.

    Rev Infect Dis

    (1987)
  • PhelpsCE.

    Bug-drug resistance: sometimes less is more.

    Med Care

    (1989)
  • Cited by (0)

    Supported in part by grants from the Centers for Disease Control and Prevention (UR8/CCU715087).

    View full text