Patterns, Predictors, and Intercenter Variability in Empiric Gram-Negative Antibiotic Use Across 928 United States Hospitals

Goodman, Katherine E; Baghdadi, Jonathan; Magder, Laurence S.; Heil, Emily L.; Sutherland, Mark; Dillon, Ryan; Puzniak, Laura; Harris, Anthony D.

doi:10.1093/cid/ciac504

Cited by 13 publications

(16 citation statements)

References 53 publications

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“…The application of empirical antibiotics is dependent on the clinician’s experience and varies widely among individuals. 31 As shown in our results, the empirical antibiotic application is appropriate for only about half of the patients with sepsis. In the absence of an etiologic report, it can be difficult and confusing for clinicians to make further adjustments to antibiotics.…”

Section: Discussionsupporting

confidence: 53%

Clinical Characteristics and the Effect of Timing for Metagenomic Next-Generation Sequencing in Critically Ill Patients with Sepsis

He¹,

Liu²,

Chen³

et al. 2022

IDR

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Background: Metagenomic next-generation sequencing (mNGS) has a good performance for the identification of pathogens in infectious diseases, but few studies on the clinical characteristics of mNGS and the effect of timing for mNGS in critically ill patients with sepsis. Methods: We retrospectively included all patients diagnosed with sepsis after admission to the intensive care unit (ICU) of a university-affiliated hospital between Aug 1, 2019 and Apr 1, 2021. During the study period, pathogens for all enrolled subjects were obtained by mNGS. We analyzed the composition and positive rate of different samples type for mNGS. And then we used the univariable and multivariable logistic regression to explore the risk factors associated with all-cause mortality at 28 days. Results: A total of 87 patients were included and 87 samples were analyzed among these patients. The most common sample for mNGS was bronchoalveolar lavage fluid (BALF), about 84% (73/87). The positive rate of pathogens identification by mNGS was higher than conventional culture (92% vs 36%, p < 0.001). In addition to the pathogens detected by conventional culture, mNGS can detect more viruses and fungi. Based on the mNGS report, clinicians made adjustments to the antibiotic regimen for 72% patients. The multivariate binary logistic regression analysis suggested that age (OR, 1.036; 95% CI, 1.005-1.067; p = 0.021) and the sequential organ failure assessment (SOFA) score on the day of mNGS sampling were independent risk factors of death at 28 days (OR, 1.204; 95% CI, 1.038-1.397; p = 0.014). Conclusion:In critically ill patients with sepsis, the most common sample type for mNGS was BALF, and the positive rate of mNGS is higher than conventional cultures, especially in viruses and fungi. Meanwhile, mNGS can guide clinicians in adjusting antibiotic regimens. Age and the SOFA score on the day of mNGS sampling were independent risk factors for death.

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Section: Discussionsupporting

confidence: 53%

Clinical Characteristics and the Effect of Timing for Metagenomic Next-Generation Sequencing in Critically Ill Patients with Sepsis

He¹,

Liu²,

Chen³

et al. 2022

IDR

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“…The study sample included all adult patients who were discharged from a Premier database hospital in calendar year 2019 and who were started on Gram-negative antibiotics during the ‘empiric window’, meaning within Days 0–2 of hospitalization. 1 Hospital Day 0 was the day of presentation to or arrival at the hospital including time spent in the emergency department. Patients were excluded if discharged on the same day that empiric Gram-negative antibiotics were initiated.…”

Section: Methodsmentioning

confidence: 99%

“… 22 , 23 Overall spectrum of activity was ranked using four categories (narrow, broad, extended, protected) and was determined by the broadest-spectrum Gram-negative antibiotic administered in a single day (see Figure 1 for categories). 1 , 23 The secondary outcome was antibiotic de-escalation, defined as a decrease in the spectrum of activity or number of antibiotics, within 5 days of initiation. 23 Definitions were operationalized in consultation with physician and pharmacist members of the antibiotic stewardship programme (J.D.B., J.B., E.L.H., K.C.)…”

Section: Methodsmentioning

confidence: 99%

“…Theoretically, empiric antibiotics should represent an educated guess at appropriate coverage based on the patient’s condition, medical history, prior culture results and the facility’s antibiogram. 1–3 However, in administrative data, prescribing patterns vary widely between hospitals and are often unexplainable by patient-level factors. 1 …”

Section: Introductionmentioning

confidence: 99%

“… 1–3 However, in administrative data, prescribing patterns vary widely between hospitals and are often unexplainable by patient-level factors. 1 …”

Section: Introductionmentioning

confidence: 99%

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Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients

Baghdadi

Goodman

Magder

et al. 2023

JAC-Antimicrobial Resistance

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Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur’s D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9–20.1), broad-spectrum (HR 10.3; 95% CI: 9.78–10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30–3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91–1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35–1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61–2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65–1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.

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Clinicians' interpretation of thresholds in hospital antibiograms for gram‐negative rod infections: A survey and contingent valuation study of hospitalists

Hasegawa,

Harris,

Gupta

et al. 2024

Journal of Hospital Medicine

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Clinical guidelines suggest that hospital antibiograms are a key component when deciding empiric therapy, but little is known about how often clinicians use antibiograms and how they influence clinicians' empiric therapy decisions. We surveyed hospitalists at seven healthcare systems in the United States on their reported practices related to antibiograms and their hypothetical prescribing for four clinical scenarios associated with gram‐negative rod pathogens. Each was given a randomly assigned antibiogram susceptibility percentage, and we used contingent valuation analysis to assess whether the antibiogram susceptibility percentage was associated with prescribing practices. Of the 193 survey responders, only 52 (26.9%) respondents reported using antibiograms more than monthly. Across all four clinical scenarios, there was no evidence that antibiogram susceptibility levels influenced antibiotic prescribing practices. With limited utilization and no evidence that they influenced practice, antibiograms may have a limited role in hospitalist care delivery for common gram‐negative rod infections.

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Patterns, Predictors, and Intercenter Variability in Empiric Gram-Negative Antibiotic Use Across 928 United States Hospitals

Cited by 13 publications

References 53 publications

Clinical Characteristics and the Effect of Timing for Metagenomic Next-Generation Sequencing in Critically Ill Patients with Sepsis

Clinical Characteristics and the Effect of Timing for Metagenomic Next-Generation Sequencing in Critically Ill Patients with Sepsis

Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients

Clinicians' interpretation of thresholds in hospital antibiograms for gram‐negative rod infections: A survey and contingent valuation study of hospitalists

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