Optimizing the Management of Uncomplicated Gram-Negative Bloodstream Infections: Consensus Guidance Using a Modified Delphi Process

Abstract

Background Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions. Methods Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds. Results Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable. Conclusions In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.

Use of Antimicrobials for Bloodstream Infections in the Intensive Care Unit, a Clinically Oriented Review

“…A rapid decrease of biomarkers such as PCT or CRP might be interesting to reduce the duration of therapy [68,71,72]. For uncomplicated GNB BSIs, it is not necessary to send repeat BC to ensure bacterial clearance [3]. Otherwise, at least one set of BCs sent at day 2-4 is required.…”

“…Complicated or uncomplicated, which was recently defined as a having definite source (among urinary, catheter, intra-abdominal, pneumonia, skin or soft tissues), and effective source control, in a non-immunocompromised patient, and with clinical improvement after 72 h of antimicrobial therapy (at least defervescence and haemodynamic stability) [3]. 4.…”

Antibiotic stewardship in the era of precision medicine

“… 53 The following criteria can be used to decide if conversion to oral therapy is indicated: (i) susceptibility to an appropriate oral agent is demonstrated; (ii) the patient is hemodynamically stable; (iii) reasonable source control measures have occurred; and (iv) concerns about insufficient intestinal absorption are not present. 54 …”

Shorter durations of antibiotic therapy in organ transplant

“…Although the ongoing debate regarding the management of gram-negative rod bacteremia in SOT patients remains, the consensus amongst a panelist of infectious disease physicians and pharmacists suggested consideration of more nuanced factors when making management decisions including type of transplanted organ, level of immunosuppression, time since transplant, and treatment for rejection. They agreed that the most immunocompromised SOT patients included those with recent transplantation and ongoing risk for opportunistic infections [39]. Although details regarding the transplanted organ, time from transplantation, and degree of immunosuppression are not specifically outlined in these RCTs, a shorter duration of therapy for gram-negative rod bacteremia can be considered in SOT populations, especially in the absence of higher risk immunocompromising factors.…”