Saturday, March 17, 2018

An interesting paper about antibiotic stewardship

This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE (Enterococcus faecium/faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus, inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions.

Yeah, well, we already knew that antibiotic delay makes things worse. What’s interesting about this report is that it’s way, way worse for gram negative bacteremia. But what does this have to do with antibiotic stewardship? Promptness of antibiotic administration is a concept that was around long before “antibiotic stewardship” became a buzzword.

Webster defines stewardship this way:

the conducting, supervising, or managing of something; especially : the careful and responsible management of something entrusted to one's care

To the uninitiated, antibiotic stewardship might just mean optimal use of antibiotics but to those in the know special meanings apply. Given the narrative of the day that we’re headed for a gram negative antimicrobial apocalypse many stewardship programs emphasize restriction of gram negative drugs. If front end restrictions delay first dose administration that might be a bad thing according to this report.

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