Initial Antibiotic Choice Research Articles

Developing a national ‘low risk’ febrile neutropenia framework for use in children and young people's cancer care

A Delphi study was undertaken to develop a framework guidance that would rationalise and standardise the care of children with febrile neutropenia (FNP) across the UK. A mailed Delphi survey was undertaken with health professionals working in children's cancer units. The survey employed two rounds of feedback on 22 practice statements drawn from a systematic review of clinical evidence. Consensus was assumed for any statement where 80+ % of respondents indicated that they "agreed" or "strongly agreed". Consensus was reached on 21 of the 22 practice statements in round 1 that were categorised into six areas: definition of fever and neutropenia, initial management and choice of antibiotic, defining low-risk patients, strategy in low-risk patients and alternative approaches. Consensus could not be reached on whether patients needed to be afebrile to be suitable for discharge and the required length of outpatient antibiotic treatment. A Delphi survey allowed the successful development of a national framework for identification and management of children with FNP. The use of an existing well-functioning professional network was key in this project's success.

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Introduction: Nationally, 93% of patients with community-acquired pneumonia (CAP) receive guideline-concordant therapy. Severe CAP, defined as CAP treated in the ICU, accounts for up to 35% of CAP. Early initiation of antibiotic treatment is extremely important for these patients, but the proportion of patients that receive guideline-concordant therapy is unknown. Hypothesis: Not all patients with severe CAP receive guideline-concordant care. Methods: Using a large national database, we included patients who were discharged between 7/07-6/10; had a principal diagnosis of pneumonia or a principal diagnosis of sepsis or respiratory failure combined with a secondary diagnosis of pneumonia; and, by the second hospital day, had been admitted to the ICU, undergone a chest radiograph, and were treated with antibiotics. We excluded patients with health care-associated pneumonia and those in whom pneumonia was not present on admission. Initial treatment regimens were defined as guideline-concordant if, during the first two days of hospitalization, the patient received coverage for typical and atypical CAP pathogens. Results: 20,704 patients at 346 hospitals met inclusion criteria. Inpatient mortality was 14.1%. Mechanical ventilation was initiated by day 2 in 8,069 (39%) and on day 3 or later in 1,385 (7%). Most patients (85%) were initially treated with guideline-concordant therapy. Among 17,639 patients who received guideline-concordant regimens, 4028 (23%) received coverage for typical and atypical CAP organisms but not Methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas; 1,080 (6%) received additional coverage for MRSA; 6,219 (35%) received coverage for Pseudomonas; and 6,312 (36%) received coverage for both MRSA and Pseudomonas. Among 3,065 patients who initially received guideline-discordant therapy, most (2,925, 95%) received no coverage for atypical organisms. Conclusions: There is variation in initial antibiotic choice for severe CAP. Although most patients received guideline-concordant regimens, about 15% received no initial coverage for atypical organisms.

EComment. Mitral and aortic valve endocarditis caused by Streptococcus constellatus

Concistre and colleagues reported their experience with the treatment of mitral and aortic valve infective endocarditis (IE) caused by Streptococcus constellatus [1]. I think there are some points that should be discussed. Nowadays, Staphylococci and Streptococci are the most common causative microorganisms for native valve IE. In contrast to Staphylococci, Streptococci are rarely resistant to penicillin G, which is recommended by modern guidelines for treatment of streptococcal IE in combination with gentamicin [2]. Other approved options for such cases are third generation cephalosporins – ceftriaxone, again with gentamicin. This regimen may be preferable due to a larger spectrum of activity, covering penicillin-resistant cocci. Furthermore, it is much more convenient for patients and personnel (injection of ceftriaxone once daily compared to six doses of penicillin G per day). The described patient stayed for a long time in the department of infective disease. Unfortunately, all periods of disease before admission to the cardiac surgery unit is like a “black box”: there is no information concerning predisposing factors, concomitant pathology, diagnostics and treatment provided etc. These data are essential in understanding the logic behind the initial antibiotic choice. Nevertheless with regards to the above-mentioned guidelines, in cases of native valve IE with unknown flora, initial antibiotics must cover most common pathogens, such as Staphylococci, Streptococci and Enterococci [2]. In light of this, the penicillin G-gentamicin combination seemed to be insufficient, especially in a patient who had been transferred from another ward and had previously received antibiotics. In our practice, we tend to start with a more reliable ceftriaxon + vancomycin regimen for empirical perioperative treatment of IE with unidentified etiology for such cases. After receiving microbiological data, including blood and tissue cultures, initial antibiotics regimen can be adjusted, if necessary. There is no doubt that the published case report is interesting owing to the rarity of S. constellatus as an etiological factor of IE. During our more than 10 years of surveillance at the Bakoulev Scientific Center for Cardiovascular Surgery (Moscow, Russia), where more than 4000 operations with cardiopulmonary bypass are performed annually, we have had only 5 consecutive blood cultures with S. constellatus (all in paediatric patients with non-IE pathology; all strains were susceptible to penicillin). There were no cases of S. constellatus isolation from intraoperatively resected valvular tissues in patients with IE. Returning back the present case, I suppose that if adequate anti-bacterial therapy had been started at an early stage, complications and subsequent requirement of surgery might have been avoided in this elderly patient.

Editorial: How nurses can support the Surviving Sepsis Campaign

Editorial: How nurses can support the Surviving Sepsis Campaign

Audit of BMT antibiotic febrile neutropenia guidelines

The bone marrow transplant (BMT) antibiotic febrile neutropenia guidelines were updated in 2009. Due to national guidance on prudent prescribing of antimicrobials this is a priority for audit.1ObjectiveTo assess whether...

Empiric antimicrobial therapy and infectious diarrhea. Do we need local guidelines?

Background In the management of acute diarrhea, administration of antibiotics may be indicated. Appropriate antimicrobial therapy can shorten illness, reduce morbidity and can be life-saving in invasive infections. Emergence of microbial strains resistant to commonly used antibiotics means that treatment failures may become common. Because of changing patterns of resistance, knowledge of recent local patterns of susceptibility can guide the initial choice of antibiotics. Methods A retrospective study was conducted to investigate the epidemiology of infective gastroenteritis in patients over 14 years old in the region of Chania (Crete). We reviewed all positive stool cultures and susceptibilities of the pathogens recovered from patients with symptoms of acute diarrhea, from 2003 until October 2010. Results Out of 194 positive stool cultures, we observed 139 cases of Salmonella enterica and 48 cases of Campylobacter jejuni. During the last 3 years of observation there was an increased incidence of C. jejuni, especially after the tap water outbreak that occurred in our region in 2009. Discussion In the vast majority of acute diarrhea in adults, antibiotics are of no benefit and overprescription may confer to side effects, costs and emergence of resistance. Antibiotics are initiated in cases of febrile diarrheas especially those believed to have moderate to severe disease. Considering the increased incidence of C. jejuni and the resistance of the great majority of isolated strains to quinolones as well as the sensitivity of Salmonella spp. to azithromycin, administration of azithromycin empirically for acute diarrhea, when indicated, could be appropriate in our region.

Methicillin-Resistant Staphylococcus aureus USA300 Clone as a Cause of Lemierre's Syndrome

We describe a case of a young woman who had methicillin-resistant Staphylococcus aureus USA300 clone (MRSA-USA300)-associated Lemierre's syndrome and secondary necrotizing pneumonia and cerebral infarcts. We also review 11 cases of S. aureus-associated Lemierre's syndrome reported in the literature from 1965 to 2010. Recognition of S. aureus as an emergent cause of Lemierre's syndrome informs the initial empirical antibiotic choice for this life-threatening condition and may positively impact patient outcomes.

Randomized Controlled Trial of Cephalexin Versus Clindamycin for Uncomplicated Pediatric Skin Infections

To compare clindamycin and cephalexin for treatment of uncomplicated skin and soft tissue infections (SSTIs) caused predominantly by community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA). We hypothesized that clindamycin would be superior to cephalexin (an antibiotic without MRSA activity) for treatment of these infections. Patients aged 6 months to 18 years with uncomplicated SSTIs not requiring hospitalization were enrolled September 2006 through May 2009. Eligible patients were randomly assigned to 7 days of cephalexin or clindamycin; primary and secondary outcomes were clinical improvement at 48 to 72 hours and resolution at 7 days. Cultures were obtained and tested for antimicrobial susceptibilities, pulsed-field gel electrophoresis type, and Panton-Valentine leukocidin status. Of 200 enrolled patients, 69% had MRSA cultured from wounds. Most MRSA were USA300 or subtypes, positive for Panton-Valentine leukocidin, and clindamycin susceptible, consistent with CA-MRSA. Spontaneous drainage occurred or a drainage procedure was performed in 97% of subjects. By 48 to 72 hours, 94% of subjects in the cephalexin arm and 97% in the clindamycin arm were improved (P = .50). By 7 days, all subjects were improved, with complete resolution in 97% in the cephalexin arm and 94% in the clindamycin arm (P = .33). Fevers and age less than 1 year, but not initial erythema > 5 cm, were associated with early treatment failures, regardless of antibiotic used. There is no significant difference between cephalexin and clindamycin for treatment of uncomplicated pediatric SSTIs caused predominantly by CA-MRSA. Close follow-up and fastidious wound care of appropriately drained, uncomplicated SSTIs are likely more important than initial antibiotic choice.

Clinical characteristics and therapeutic outcome of Gram-negative bacterial spinal epidural abscess in adults

Gram-negative (G(−)) bacterial spinal epidural abscess (SEA) in adults is uncommon. Of the 42 adult patients with bacterial SEA admitted to the Chang Gung Memorial Hospital – Kaohsiung, between 2003 and 2007, 12 with G(−) SEA were included in this study. Of these 12 patients, seven were men and five were women; their ages ranged between 17 years and 81 years (median = 72.5 years, mean = 62.5 years). The patients were admitted at different stages of symptom onset (four were in the acute stage and four each in the subacute and chronic stages) and at different levels of neurologic deficit severity, ranging from back pain to paraplegia. Of these 12 patients, 11 had a medical and/or neurosurgical condition as the preceding event and four had a concomitant infection at other sites. Back pain (83%, 10/12) was the most common clinical presentation, followed by paraparesis (50%, 6/12), radiating pain (33%, 4/12), and urinary retention (25%, 3/12). The following causative G(−) pathogens were detected: Klebsiella pneumoniae (three patients), Salmonella spp. (three), Escherichia coli (two), Enterobacter spp. (two), Aeromonas hydrophila (one), and Prevotella melaninogenica (one). Both Enterobacter strains were resistant to multiple antibiotics. Of the 12 patients, eight (66.7%) had spontaneous SEA, whereas the remaining four had postneurosurgical SEA. Thoracic, lumbar, and thoracolumbar spine segments were the most commonly affected. After receiving medical and/or surgical treatment, 10 of the 12 patients (83%) survived, and all 10 recovered well. In conclusion, G(−) bacterial SEA accounted for 28.5% (12/42) of adult SEA. The causative G(−) pathogens found in this study were different from those reported in Western countries, and the strains noted in our study had multiple antibiotic resistance. Our findings suggest that the choice of initial empirical antibiotics for SEA should be carefully considered.

Antibiotic susceptibility patterns of Staphylococcus aureus isolates from Australian children

Staphylococcus aureus is an important cause of serious illness in children. Antibiotic resistance is an international problem and affects initial antibiotic choice. We aimed to describe susceptibility patterns of S. aureus isolates from Australian children to inform optimal empiric treatment of staphylococcal infections in this population. We analysed susceptibility data for all S. aureus isolates from children at Australian tertiary paediatric hospitals in 2006. Susceptibility rates were compared between hospitals and states, and with published studies of S. aureus isolates from Australian adults. Overall, the proportion of methicillin-resistant S. aureus (MRSA) in Australian children was low (9.8%), and in each state it was less than for the comparable adult population. There were significant differences in susceptibility patterns between different states. Most MRSA isolates were susceptible to clindamycin (73%) and all isolates were reported as susceptible to vancomycin. Susceptibility patterns for isolates from bacteraemic patients were similar to those for isolates from all patients. These data support current Australian recommendations for the use of flucloxacillin or a first-generation cephalosporin as initial treatment of non-life-threatening staphylococcal infections. However, broad spectrum antibiotic therapy including agents that are effective against MRSA should be considered for more serious infections. Appropriate specimens should be collected for susceptibility testing to enable directed treatment for MRSA and other resistant organisms. This study highlights the importance of using local, age-specific data in planning antibiotic treatment guidelines, as results vary substantially from city to city and between adults and children.

Staphylococcus Aureus Peritonitis in Australian Peritoneal Dialysis Patients: Predictors, Treatment, and Outcomes in 503 Cases

Staphylococcus aureus peritonitis is a serious complication of peritoneal dialysis (PD). Since reports of the course and treatment of S. aureus peritonitis have generally been limited to small, single-center studies, the aim of the current investigation was to examine the frequency, predictors, treatment, and clinical outcomes of this condition in all 4675 patients receiving PD in Australia between 1 October 2003 and 31 December 2006. 3594 episodes of peritonitis occurred in 1984 patients and 503 (14%) episodes of S. aureus peritonitis occurred in 355 (8%) individuals. 273 (77%) patients experienced 1 episode of S. aureus peritonitis, 52 (15%) experienced 2 episodes, 19 (5%) experienced 3 episodes, and 11 (3%) experienced 4 or more episodes. The predominant antibiotics used as initial empiric therapy were vancomycin (61%) and cephazolin (31%). Once S. aureus was isolated and identified, the prescription of vancomycin did not appreciably change for methicillin-sensitive S. aureus (MSSA) peritonitis (59%) and increased for methicillin-resistant S. aureus (MRSA) peritonitis (84%). S. aureus peritonitis was associated with a higher rate of relapse than non-S. aureus peritonitis (20% vs 13%, p < 0.001) but comparable rates of hospitalization (67% vs 70%, p = 0.2), catheter removal (23% vs 21%, p = 0.4), hemodialysis transfer (18% vs 18%, p = 0.6), and death (2.2% vs 2.3%, p = 0.9). MRSA peritonitis was independently predictive of an increased risk of permanent hemodialysis transfer [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.17 - 3.82] and tended to be associated with an increased risk of hospitalization (OR 2.00, 95% CI 0.96 - 4.19). The initial empiric antibiotic choice between vancomycin and cephazolin was not significantly associated with clinical outcomes, but serious adverse outcomes were more likely if vancomycin was not used for subsequent treatment of MRSA peritonitis. In conclusion, S. aureus peritonitis is a serious complication of PD, involves a small proportion of patients, and is associated with a high rate of relapse and repeat episodes. Other adverse clinical outcomes are similar to those for peritonitis overall but are significantly worse for MRSA peritonitis. Empiric initial therapy with either vancomycin or cephazolin results in comparable outcomes, provided vancomycin is prescribed when MRSA is isolated and identified.

Why can't I prescribe that antibiotic? The role of antimicrobial stewardship programmes in modern medicine

Why can't I prescribe that antibiotic? The role of antimicrobial stewardship programmes in modern medicine

121: Prognosis of Urosepsis Patients Who Are Treated by Inappropriate Initial Antimicrobial Therapy in the Emergency Department

Urosepsis is known to have a better prognosis than other types of sepsis. However, it is not clear whether there is an increase in adverse outcome if there is erroneous initial antimicrobial therapy administration followed later, by a change to appropriate therapy after cultures results become available. We categorized patients with urosepsis into two groups with regard to appropriate and inappropriate initial antibiotic choice and measured the outcome, which included the difference of mortality rate and cost of hospitalization.

Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases

BackgroundThere has not been a comprehensive, multi-centre study of streptococcal peritonitis in patients on peritoneal dialysis (PD) to date.MethodsThe predictors, treatment and clinical outcomes of streptococcal peritonitis were examined by binary logistic regression and multilevel, multivariate poisson regression in all Australian PD patients involving 66 centres between 2003 and 2006.ResultsTwo hundred and eighty-seven episodes of streptococcal peritonitis (4.6% of all peritonitis episodes) occurred in 256 individuals. Its occurrence was independently predicted by Aboriginal or Torres Strait Islander racial origin. Compared with other organisms, streptococcal peritonitis was associated with significantly lower risks of relapse (3% vs 15%), catheter removal (10% vs 23%) and permanent haemodialysis transfer (9% vs 18%), as well as a shorter duration of hospitalisation (5 vs 6 days). Overall, 249 (87%) patients were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The majority of streptococcal peritonitis episodes were treated with either intraperitoneal vancomycin (most common) or first-generation cephalosporins for a median period of 13 days (interquartile range 8–18 days). Initial empiric antibiotic choice did not influence outcomes.ConclusionStreptococcal peritonitis is a not infrequent complication of PD, which is more common in indigenous patients. When treated with either first-generation cephalosporins or vancomycin for a period of 2 weeks, streptococcal peritonitis is associated with lower risks of relapse, catheter removal and permanent haemodialysis transfer than other forms of PD-associated peritonitis.

Does De-Escalation of Antibiotic Therapy for Ventilator-Associated Pneumonia Affect the Likelihood of Recurrent Pneumonia or Mortality in Critically Ill Surgical Patients?

Ventilator-associated pneumonia (VAP) is a leading cause of mortality in critically ill patients. Although previous studies have shown that de-escalation therapy (DT) of antibiotics may decrease costs and the development of resistant pathogens, minimal data have shown its effect in surgical patients or in any patients with septic shock. We hypothesized that DT for VAP was not associated with an increased rate of recurrent pneumonia (RP) or mortality in a high acuity cohort of critically ill surgical patients. All surgical intensive care unit (SICU) patients from January 2005 to May 2007 with VAP diagnosed by quantitative bronchoalveolar lavage with a positive threshold of 10,000 CFU/mL were identified. Data collected included age, gender, Acute Physiologic and Chronic Health Evaluation Score III (A3), type of bacterial or other pathogen, antibiotics used for initial and final therapy, mortality, RP, and appropriateness of initial therapy (AIT). Patients were designated as receiving AIT, DT, or escalation of antibiotic therapy based on microbiology for their VAP. One hundred thirty-eight of 1,596 SICU patients developed VAP during the study period (8.7%). For VAP patients, the mean Acute Physiologic and Chronic Health Evaluation III score was 82.7 points with a mean age of 63.8 years. The RP rate was 30% and did not differ between patients receiving DT (27.3%) and those who did not receive DT (35.1%). Overall mortality was 37% (55% predicted by A3 norms) and did not differ between those receiving DT (33.8%) or not (42.1%). The most common pathogens for primary VAP were methicillin-resistant Staphylococcus aureus (14%), Escherichia coli (11%), and Pseudomonas aeruginosa (9%) whereas P. aeruginosa was the most common pathogen in RP. The AIT for all VAP was 93%. De-escalation of therapy occurred in 55% of patients with AIT whereas 8% of VAP patients required escalation of antibiotic therapy. The most commonly used initial antibiotic choice was vancomycin/piperacillin-tazobactam (16%) and the final choice was piperacillin-tazobactam (20%). Logistic regression demonstrated no specific parameter correlated with development of RP. Higher A3 (Odds ratio, 1.03; 95% confidence interval, 1.01-1.05) was associated with mortality whereas lack of RP (odds ratio, 0.31; 95% confidence interval, 0.12-0.80), and AIT reduced mortality (odds ratio, 0.024; 95% confidence interval, 0.007-0.221). Age, gender, individual pathogen, individual antibiotic regimen, and the use of DT had no effect on mortality. De-escalation therapy did not lead to RP or increased mortality in critically ill surgical patients with VAP. De-escalation therapy was also shown to be safe in patients with septic shock. Because of its acknowledged benefits and lack of demonstrable risks, de-escalation therapy should be used whenever possible in critically ill patients with VAP.

Comparison of initial antibiotic choice and treatment of cellulitis in the pre- and post–community-acquired methicillin-resistant Staphylococcus aureus eras

Treatment success of cellulitis in the age of community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA). A comparison of initial antibiotic choice and treatment success in the pre- and post-CAMRSA eras. Objective The objective of this study is to determine antibiotic prescribing patterns and treatment failure rates for cellulitis in the pre- and post-CAMRSA eras. Methods We performed an electronic chart review of patients seen in our emergency department with cellulitis in 2000 and 2005. Inclusion criteria included age 18 years or more and received a single oral antibiotic for cellulitis. Exclusion criteria were incision and drainage, surgery, or admission on initial visit. Treatment failure was defined as a repeat visit in the subsequent 30 days and a change in antibiotics, admission to the hospital, incision and drainage of abscess, or surgical intervention. Antibiotic-prescribing practices and treatment failure rates were then compared in the pre- and post-CAMRSA eras. Results There was a significant decrease in β-lactam antibiotics and an increase in CAMRSA-effective antibiotics prescribed in 2005 vs 2000. The difference in treatment failure rates of the β-lactams and CAMRSA antibiotics was statistically insignificant. There has not been an increase in failure rates of the β-lactam antibiotics for simple cellulitis since the emergence of CAMRSA. Conclusion Our study demonstrates that prescribing practices for simple cellulitis have changed since the emergence of CAMRSA. This may not be appropriate because β-lactam antibiotics perform as well as ‘CAMRSA antibiotics’ in our study.

Pseudomonas Peritonitis in Australia

Pseudomonas peritonitis is a serious complication of peritoneal dialysis. To date, there as been no comprehensive, multicenter study of this condition. The predictors, treatment, and clinical outcomes of Pseudomonas peritonitis were examined by binary logistic regression and multilevel, multivariate Poisson regression in all Australian PD patients in 66 centers between 2003 and 2006. A total of 191 episodes of Pseudomonas peritonitis (5.3% of all peritonitis episodes) occurred in 171 individuals. Its occurrence was independently predicted by Maori/Pacific Islander race, Aboriginal/Torres Strait Islander race, and absence of baseline peritoneal equilibration test data. Compared with other organisms, Pseudomonas peritonitis was associated with greater frequencies of hospitalization (96 versus 79%; P = 0.006), catheter removal (44 versus 20%; P < 0.001), and permanent hemodialysis transfer (35 versus 17%; P < 0.001) but comparable death rates (3 versus 2%; P = 0.4). Initial empiric antibiotic choice did not influence outcomes, but subsequent use of dual anti-pseudomonal therapy was associated with a lower risk for permanent hemodialysis transfer (10 versus 38%, respectively; P = 0.03). Catheter removal was associated with a lower risk for death than treatment with antibiotics alone (0 versus 6%; P < 0.05). Pseudomonas peritonitis is associated with high rates of catheter removal and permanent hemodialysis transfer. Prompt catheter removal and use of two anti-pseudomonal antibiotics are associated with better outcomes.

A cost-minimisation analysis comparing different antibiotic regimens used in treating all-cause bacterial pneumonia in Hong Kong

Background: To find out the antibiotic treatment regimens with the lowest cost for all-cause bacterial pneumonia, a study to compare the costs of different antibiotic regimens in the treatment of patients diagnosed with all-cause bacterial pneumonia who required hospitalisation was carried out.Methodology: This was a multicentre, retrospective study of patient medical records. The primary aim was to examine whether the initial choice of antibiotic had affected the total cost of treatment, while the secondary aim was to find out whether the initial choice of antibiotic had affected the initial treatment failure rates and death rates. A cost-minimisation analysis (CMA) from a public hospital perspective was employed.Results: A total of 333 patient medical case notes were reviewed. The most commonly prescribed antibiotic regimen was amoxycillin-clavulanate (AC) followed by amoxycillin-clavulanate plus macrolide (ACM) and quinolone (Q). In the study population, no statistical significance could be detected between the mean cost of the three regimens. In the subgroup analysis of patients with a history of chronic obstructive pulmonary disease (COPD) and patients with a history of smoking, the Q regimen appeared to be the least expensive.Conclusion: In the study population, no significant difference could be identified between the mean cost of the three antibiotic regimens. In a special populations such as patients with a history of COPD and patients with a history of smoking, the Q regimen appeared to be superior. Further studies in these areas are needed.

Antimicrobial Therapy Escalation and Hospital Mortality Among Patients With Health-Care-Associated Pneumonia: A Single-Center Experience

Patients with health-care-associated pneumonia (HCAP) are frequently infected with a resistant pathogen and receive inappropriate empiric antibiotics (ie, pathogens resistant to administered treatment). Initial inappropriate treatment has been shown to increase hospital mortality. It is not known whether escalation in response to culture results mitigates this risk. We identified patients admitted with a culture-positive pneumonia between January 2003 and December 2005. HCAP patients met one or more of the following criteria indicating ongoing contact with the health-care system: recent hospitalization (< or = 12 months), admission from a nursing home, immunosuppression, or long-term dialysis. We compared survivors to nonsurvivors among those patients with HCAP still hospitalized beyond 48 h. Of 431 HCAP patients, 396 patients (92%) were alive and still hospitalized beyond 48 h. The crude mortality rate was 21.5%. Compared to survivors, nonsurvivors were significantly more likely to be treated with inappropriate empiric antibiotics (37.6% vs 24.1%, p = 0.013). Although mortality was higher among patients receiving inappropriate than appropriate therapy (30.0% vs 18.3%, p = 0.013), this difference was more pronounced among nonbacteremic patients (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.26 to 4.75) than bacteremic patients (OR, 1.25; 95% CI, 0.41 to 3.57). In a logistic regression, inappropriate empiric antibiotic treatment among nonbacteremic patients was independently associated with mortality (OR, 2.88; 95% CI, 1.46 to 5.67); treatment escalation did not attenuate the risk of death. Among HCAP patients alive and hospitalized beyond 48 h, hospital mortality was high and, in the absence of bacteremia, greater with initial inappropriate antibiotic treatment. Despite subsequent escalation, initial inappropriate antibiotic choice nearly tripled the risk of hospital death.

Peritoneal Fluid Cultures Rarely Alter Management in Patients with Ascites

The objective of this study is to determine if the peritoneal fluid culture results in the ascites patient being evaluated for spontaneous bacterial peritonitis (SBP) in the Emergency Department (ED) are used by the inpatient physician to appropriately alter empiric antibiotic treatment. We performed a retrospective study of all ascitic fluid samples sent from the ED between January 1, 2002 and December 31, 2004. Exclusion criteria included peritoneal fluid samples sent from peritoneal dialysis patients and those undergoing diagnostic peritoneal lavage for trauma. Medical records were examined to determine culture results, initial antibiotic choices, and subsequent changes in antibiotics by the inpatient physician in response to the culture results. The primary outcome measure was the percentage of cases in which ED peritoneal fluid culture results caused inpatient physicians to appropriately change antibiotic coverage. There were 201 ascitic fluid samples, of which 7 (3.5%; 95% confidence interval [CI] 1.4%-7.0%) had a pathogen identified. Of these, only 1 (0.5%; 95% CI .01%-2.4%) resulted in an appropriate change in empiric antibiotic therapy. Although there were additional opportunities for appropriately using the culture results to change the antibiotic coverage in 2 (1%; 95% CI 0.1%-3.6%) patients, coverage was not changed. In fact, it was changed inappropriately in these 2 patients, and in an additional patient on appropriate empiric therapy. The yield from ascitic fluid cultures was low, and when positive, did not appropriately change management according to microbiologic criteria.