Abstract
Purpose: The aim of the present study was to determine whether de-escalation guided by blood cultures for patients with a diagnosis of sepsis, severe sepsis or septic shock reduces mortality, and antimicrobial drug resistance (ADR). Methods: A prospective, single-center, cohort study was conducted with adults admitted to the ICU with a diagnosis of sepsis, severe sepsis, or septic shock at a public hospital in Sorocaba, State of São Paulo, Brazil, from January 2013 to December 2013. We excluded patients who had negative blood cultures. Patients who had replaced the initial empirical broad-spectrum antibiotic therapy (EAT) by the antibiotic therapy guided by blood cultures were compared with those who continued receiving EAT. The outcome included mortality and antimicrobial drug resistance. We used the Cox regression (proportional hazards regression) and the Poisson regression to analyze the association between antibiotic therapy guided by blood cultures (ATGBC) and outcomes. The statistical adjustment in all models included the following variables: sex, age, APACHE II (Acute Physiology And Chronic Health Evaluation II) score and SOFA (Sequential Organ Failure Assessment) score. Results: Among the 686 patients who were admitted to the intensive care unit, 91 were included in this study. The mean age of the patients was 52.7 years (standard deviation = 18.5 years) and 70.3% were male. EAT was replaced by ATGBC in 33 patients (36.3%) while 58 patients (63.7%) continued receiving EAT. Overall hospital mortality decreased from 56.9% in patients who received EAT to 48.5% in patients who received ATGBC [Hazard ratio- HR 0.44 (95% CI 0.24–0.82), p = 0.009]. There was no association between ATGBC and ADR [HR 0.90 (95% CI 0.78 – 1.03) p = 0.15]. Conclusions: Although the early and appropriate empirical EAT is undoubtedly an important factor prognostic, ATGBC can reduce the mortality in these patients.
Highlights
Sepsis remains a serious public health problem with high morbidity and mortality
Overall hospital mortality decreased from 56.9% in patients who received Empirical antibiotic therapy (EAT) to 48.5% in patients who received antibiotic therapy guided by blood cultures (ATGBC) [Hazard ratio- Hazard ratios (HRs) 0.44, p 0.009]
There was no association between ATGBC and antimicrobial drug resistance (ADR) [HR 0.90 p 0.15]
Summary
Sepsis remains a serious public health problem with high morbidity and mortality. In 2017, the most recent global estimates for sepsis incidence reported 48, 9 million incident cases of sepsis and 11 million sepsis-related deaths, representing 19.7% of all global deaths (Rudd et al, 2020). Therapeutic measures with considerable positive impacts have been widely emphasized, the management of sepsis in critically ill patients is challenging. Empirical broad-spectrum antibiotic therapy (EAT) for treating sepsis, severe sepsis, and septic shock, when appropriate, reduces mortality; there is a risk that this treatment may expose patients to the overuse of antibiotics. It can lead to increases in antibiotic resistance, costs, and drug-associated adverse events (Martínez et al, 2020; Rhee et al, 2020). Studies investigating the association between EAT and mortality among patients with sepsis have reported different findings (Paul et al, 2010). There is a relatively small number of studies that directly address the impact of the appropriate selection of antibiotic therapy in these patients (Sherwin et al, 2017)
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