133 Sepsis and Empiric Antibiotics: Should We Consider “Health Care Associated” Urinary Tract Infections?

Abstract

The objective of this study was to examine whether empiric antibiotic choices achieved adequate antimicrobial coverage in septic shock patients based on ultimate culture data. A retrospective medical record review of adult septic shock patients who presented to the emergency department (ED) of a tertiary care, academic medical center from December 2007- September 2008 was performed. Inclusion criteria consisted of: 1) Suspected or confirmed infection 2) > 2 SIRS criteria 3) Treatment with at least 1 antimicrobial agent in the ED 4) Hypotensive requiring vasopressor use. Patients were excluded if they were immunocompromised or had known active cancer. Data collected included demographics, initial vital signs and laboratory data, culture results, as well as empiric antimicrobial therapies administered in the ED. Patients were classified as presenting from either a community or health care setting. Initial empiric therapy was classified as adequate if at least 1 of the agents administered displayed in vitro activity against a culture-identified pathogen. Simple descriptive statistics including means and standard deviations (for continuous data) and frequency with percentages (for categorical data) were used to describe the study population where appropriate. A total of 112 patients were identified during the study period. Of these, 85 patients met all inclusion criteria and none of the exclusion criteria and were included in the analysis. The average age of patients was 68±15.8, and 44 (52%) were male. Thirty-eight (45%) patients in the study group presented from a health care setting. Pneumonia was the predominant infection type (38/85; 45%), followed by urinary tract infection (16/85; 19%), other (skin, soft tissue, bone, meningitis, etc; 18/85; 21%), and intra-abdominal infection (13/85; 15%). Thirty-nine patients (46%) ultimately had a positive culture. Patients presenting with pneumonia as their suspected infection source had fewer positive cultures (13/38, 34%) in comparison with UTI (9/16, 56%), intra-abdominal (8/13, 62%), or other infection (9/18, 50%) patients. Of the 39 patients, initial empiric antibiotic therapy administered in the ED adequately covered the infecting organism in 90% of patients (35/39). All patients presenting with pneumonia with positive cultures received adequate antibiotic therapy (13/13, 100%). Four (4/39; 10%) patients received empiric antimicrobial therapy in the ED which was inadequate to treat the infecting organism; in this group, all (4/4; 100%) of these patients presented with UTI, and all were classified as being from a health care setting. All resistant strains were extended spectrum beta-lactam producers (ESBLs). In this population of ED patients with septic shock, empiric antibiotic therapy was adequate for most sources of infection, such as pneumonia or intra-abdominal infection. However, inadequate empiric antimicrobial therapy occurred in a small group of uroseptic patients who were all categorized as health care exposed. Current guidelines for urinary tract infection treatment do not take into account health care setting exposure or the possibility of ESBLs. A larger, prospective study is needed to further define this risk category and determine optimal empiric antibiotics for patients with urospesis and health care setting exposure.