Abstract
BackgroundDemographic change concurrent with medical progress leads to an increasing number of elderly patients in intensive care units (ICUs). Antibacterial treatment is an important, often life-saving, aspect of intensive care but burdened by the associated antimicrobial resistance risk. Elderly patients are simultaneously at greater risk of infections and may be more restrictively treated because, generally, treatment intensity declines with age. We therefore described utilization of antibacterials in ICU patients older and younger than 80 years and examined differences in the intensity of antibacterial therapy between both groups.MethodsWe analysed 17,464 valid admissions from the electronic patient data management system of our surgical ICU from April 2006 – October 2013. Antibacterial treatment rates were defined as days of treatment (exposed patient days) relative to patient days of ICU stay and calculated for old and young patients. Rates were compared in zero-inflated Poisson regression models adjusted for patients’ sex, mean SAPS II- and TISS-scores, and calendar years yielding adjusted rate ratios (aRRs). Rate ratios exceeding 1 represent higher rates in old patients reflecting greater treatment intensity in old compared to younger patients.ResultsObserved antibacterial treatment rates were lower in patients 80 years and older compared to younger patients (30.97 and 39.73 exposed patient days per 100 patient days in the ICU, respectively). No difference in treatment intensity, however, was found from zero-inflated Poisson regression models permitting more adequate consideration of patient days with low treatment probability: for all antibacterials the adjusted rate ratio (aRR) was 1.02 (95%CI: 0.98–1.07). Treatment intensities were higher in elderly patients for penicillins (aRR 1.37 (95%CI: 1.26–1.48)), cephalosporins (aRR 1.20 (95%CI: 1.09–1.31)), carbapenems (aRR 1.35 (95%CI: 1.20–1.50)), fluoroquinolones (aRR 1.17 (95%CI: 1.05–1.30), and imidazoles (aRR 1.34 (95%CI: 1.23–1.46)).ConclusionsElderly patients were generally less likely to be treated with antibacterials. This observation, however, did not persist in patients with comparable treatment probability. In these, antibacterial treatment intensity did not differ between younger and older ICU patients, for some antibacterial classes treatment intensity was even higher in the latter. Patient-level covariates are instrumental for a nuanced evaluation of age-effects in antibacterial treatment in the ICU.
Highlights
Demographic change concurrent with medical progress leads to an increasing number of elderly patients in intensive care units (ICUs)
General treatment intensity in ICUs declines with advancing age [9,10,11,12,13], it is acknowledged that age alone should not be decisive for this [7, 9, 14]
Patients with a SAPS Simplified Acute Physiology Score II (II)- and TISSscore contributed to 72.2% of total patient days
Summary
Demographic change concurrent with medical progress leads to an increasing number of elderly patients in intensive care units (ICUs). Antibacterial therapy places intensive care physicians in a worsening dilemma of providing adequate therapy for the individual while considering the good of the single patient but of the whole ICU [6] This conflict especially applies to older patients who are on the one hand at greater risk for developing infections [7] and on the other hand may only experience limited benefit from aggressive therapy, especially at the end of life [6, 8]. General treatment intensity in ICUs declines with advancing age [9,10,11,12,13], it is acknowledged that age alone should not be decisive for this [7, 9, 14] These conflicting treatment tendencies make it unclear if current utilization of antibacterials in elderly ICU patients differs from that of younger ones. Previous antibacterial drug utilization studies in ICUs have focused on total antibacterial consumption or impacts of antibiotic stewardship programs, while data quantifying antibacterial therapy based on individual patient data are scarce
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