Impact of an antimicrobial stewardship bundle for uncomplicated gram-negative bacteremia

Abstract

Background Recent studies in gram-negative bacteremia (GNB) suggest intravenous (IV) to oral (PO) switch and short treatment durations yield similar clinical outcomes and fewer adverse events. Antimicrobial stewardship program (ASP) bundled initiatives have been associated with improved clinical outcomes for blood stream infections. Methods This single-center retrospective cohort evaluation included inpatient adults from 11/2014-10/2015 and 10/2017-9/2018 with GNB. The pre-ASP period was prior to the establishment of an ASP program. In the post-period, the ASP promoted IV to PO switches, avoidance of repeat blood cultures, and short treatment durations for patients with uncomplicated GNB. The primary outcome was duration of antibiotic therapy. Secondary outcomes included associated process measures with the bundle and clinical outcomes. Results 137 patients met criteria for inclusion, with 51 patients in the pre- group, and 86 patients in the post- group. Background characteristics were similar between groups. The median duration of therapy was 14 days (IQR = 10-16) in the pre- group and 10 days (7-14) in the post- group (p<0.001). The median day of IV to PO switch was on day 5 (4-6) in the pre- group versus day 4 (3-5) in the post- group (p=0.046). Average total hospital cost per case decreased by 27% in the post- group (p=0.19). Mortality rates and bacteremia recurrence were not significantly different between groups. Conclusions An ASP bundle for uncomplicated GNB was associated with reduced durations of therapy and earlier PO switch. These findings highlight the synergistic role of ASPs in optimizing antibiotic use and promoting patient safety.

Short‐course versus long‐course antibiotic treatment in patients with uncomplicated gram‐negative bacteremia: A systematic review and meta‐analysis

“…After reading the full texts of the remaining eleven studies, only six studies containing a total of 2689 patients were included in the systematic review and meta‐analysis 12,13,20‐23 . Two studies were excluded due to the unavailability of data 11,24 . Three studies were excluded because patients were not clearly defined as having uncomplicated gram‐negative bacteremia 25‐27 (Figure 1).…”

Oral β-Lactam Antibiotics vs Fluoroquinolones or Trimethoprim-Sulfamethoxazole for Definitive Treatment of Enterobacterales Bacteremia From a Urine Source

“…Involvement of infectious diseases and antimicrobial stewardship programs should be considered to optimize patient selection. 47 Another important consideration is that the shortest effective treatment duration is unknown, as durations shorter than 7 days have not been systematically studied, to our knowledge. 27 , 28 Therefore, we may have overestimated the association of oral antibiotics with outcomes because it is plausible that some patients were adequately treated before initiating oral step-down therapy.…”

Are Follow-Up Blood Cultures Useful in the Antimicrobial Management of Gram Negative Bacteremia? A Reappraisal of Their Role Based on Current Knowledge

“…As for GN-BSIs, relevant advances in management strategies have been made in the last few years, such as the non-inferiority demonstration of 7 vs 14 day antibiotic courses [ 10 ] and of oral step-down vs continued parental therapy [ 11 ] in uncomplicated GN-BSIs. Recently, a combined approach of rapid diagnostic testing with a bundle of antimicrobial stewardship found a decrease in readmission rate and in cost per case [ 12 ]. Anyway, the management of GN-BSIs remains poorly codified and thus prone to personal clinician judgement, as compared to Gram positive settings.…”