Program Schedule

225
Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence

Session: Poster Abstract Session: Antibiotic Stewardship
Thursday, October 9, 2014
Room: The Pennsylvania Convention Center: IDExpo Hall BC
Posters
  • Abstract#47023Development of Institutional Guidelines for Management of Gram Negative BSI.pdf (354.3 kB)
  • Background: Appropriate empirical antimicrobial therapy is associated with improved survival in patients with bloodstream infections (BSI). Antimicrobial stewardship programs can develop evidence-based institutional guidelines for empirical antimicrobial therapy of gram-negative BSI based on local data.

    Methods: Hospitalized adults with gram-negative BSI from 2011-2012 at Palmetto Health Richland and Baptist Hospitals in Columbia, SC, USA were evaluated. Multivariable logistic regression was used to identify patients with risk factors for BSI due to gram-negative bacilli that harbor antimicrobial resistance genes (Pseudomonas aeruginosa, Enterobacter, Citrobacter and Serratia species). Antimicrobial susceptibility rates of bloodstream isolates to non-restricted antibiotics were stratified by risk of antimicrobial resistance and acute severity of illness. Retained antibiotics had predefined susceptibility rates ≥90% for non-critically ill (Pitt bacteremia score <4) and ≥95% for critically ill patients (Pitt score ≥4).

    Results: Among 390 patients with gram-negative BSI, healthcare-associated (HCA) [odds ratio (OR) 3.01, 95% confidence intervals (CI) 1.52-6.32] and hospital-acquired (HA) sites of acquisition [OR 3.68, 95% CI 1.64-8.44] were identified as risk factors for BSI due to P. aeruginosa or Amp-C-producing Enterobacteriaceae as compared to community-acquired (CA) BSI (referent). Based on stratified bloodstream antibiogram (Table), ceftriaxone was recommended for empirical therapy of CA BSI in non-critically ill patients; and cefepime or piperacillin-tazobactam for HCA, HA and critically ill patients with BSI.   

    Percentage of susceptible bloodstream isolates to antibiotics by site of acquisition and Pitt score

    Antibiotic

    CA

    HCA and HA

    Pitt < 4

    (N=128)

    Pitt ≥ 4

    (N=33)

    Pitt < 4

    (N=152)

    Pitt ≥ 4

    (N=77)

    Ampicillin-sulbactam

    71

    66

    60

    71

    Ceftriaxone

    95

    91

    85

    90

    Cefepime

    96

    100

    95

    96

    Piperacillin-tazobactam

    98

    100

    95

    97

    Ciprofloxacin

    84

    82

    84

    75

    Gentamicin

    91

    97

    94

    91

    Conclusion: Incorporation of risk factors for antimicrobial resistance, local antimicrobial susceptibility rates and acute severity of illness into institutional management guidelines provides an objective evidence-based approach for optimizing empirical antimicrobial therapy for gram-negative BSI.

    Elizabeth Nimmich, MD1, Julie Ann Justo, Pharm D, MS2, P. Brandon Bookstaver, Pharm.D., BCPS, (AQ-ID), AAHIVE2, Katie Devaul, PharmD3, Joseph Kohn, Pharm.D., BCPS4, Sarah Cain, BS5, Geoffrey Turner, MD, PHD6, Helmut Albrecht, MD7 and Majdi Al-Hasan, MD7, (1)University of South Carolina School of Medicine-Palmetto Health Richland, Columbia, SC, (2)Univ. of South Carolina Coll. of Pharmacy, Columbia, SC, (3)Palmetto Health Baptist Hospital, Columbia, SC, (4)Palmetto Health Richland Hospital, Columbia, SC, (5)Univ. of South Carolina Sch. of Med., Columbia, SC, (6)Professional Pathology Services, Columbia, SC, (7)Internal Medicine, Univ. of South Carolina Sch. of Med., Columbia, SC

    Disclosures:

    E. Nimmich, None

    J. A. Justo, Cubist Pharmaceuticals: Grant Investigator, Research grant

    P. B. Bookstaver, Durata Therapeutics: Scientific Advisor, Salary
    Cubist Pharmaceuticals: Grant Investigator, Research grant

    K. Devaul, None

    J. Kohn, None

    S. Cain, None

    G. Turner, None

    H. Albrecht, None

    M. Al-Hasan, None

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