Impact of Appropriate Antimicrobial Therapy for Patients with Severe Sepsis and Septic Shock – A Quality Improvement Study

Background There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes. Material This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock. Results A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023). Conclusions The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance

Improving the diagnosis of meningitis due to enterovirus and herpes simplex virus I and II in a tertiary care hospital

Background Enterovirus and herpes simplex viruses are common causes of lymphocytic meningitis. The purpose of this study was to analyse the impact of the use molecular testing for Enteroviruses and Herpes simplex viruses I and II in all suspected cases of viral meningitis. Methods From November 18, 2008 to November 17, 2009 (phase II, intervention), all patients admitted with suspected viral meningitis (with pleocytosis) had a CSF sample tested using a nucleic acid amplification test (NAAT). Data collected during this period were compared to those from the previous one-year period, i.e. November 18, 2007 to November 17, 2008 (phase I, observational), when such tests were available but not routinely used. Results In total, 2,536 CSF samples were assessed, of which 1,264 were from phase I, and 1,272 from phase II. Of this total, a NAAT for Enterovirus was ordered in 123 cases during phase I (9.7% of the total phase I sample) and in 221 cases in phase II (17.4% of the total phase II sample). From these, Enterovirus was confirmed in 35 (28.5%, 35/123) patients during phase I and 71 (32.1%, 71/221) patients during phase II (p = 0.107). The rate of diagnosis of meningitis by HSV I and II did not differ between the groups (13 patients, 6.5% in phase I and 13, 4.7% in phase II) (p = 1.0), from 200 cases in phase I and 274 cases in phase II. Conclusions The number of cases diagnosed with enteroviral meningitis increased during the course of this study, leading us to believe that the strategy of performing NAAT for Enterovirus on every CSF sample with pleocytosis is fully justified

Risk factors associated with death for patients with severe sepsis or septic shock and documented bloodstream infection.

<p>OR  =  Odds Ratio; CI  =  Confidence Interval; APACHE  =  Acute Physiology and Chronic Health Evaluation II.</p><p>Risk factors associated with death for patients with severe sepsis or septic shock and documented bloodstream infection.</p

The most prevalent microorganisms from monomicrobial bloodstream infections and clinical outcome stratified by adequacy of antimicrobial therapy during the study period.

<p>*resistant to fluconazole.</p><p>**resistant to 3rd and 4th generation cephalosporins.</p>#<p>resistant to carbapenems.</p>##<p>resistant to methicillin.</p>###<p>resistant to vancomycin.</p><p>The most prevalent microorganisms from monomicrobial bloodstream infections and clinical outcome stratified by adequacy of antimicrobial therapy during the study period.</p

Risk factors associated with inadequate antimicrobial therapy in patients with severe sepsis or septic shock patients who had documented bloodstream infection.

<p>OR  =  Odds Ratio; CI  =  Confidance Interval; APACHE  =  Acute Physiology and Chronic Health Evaluation II.</p><p><b>ESKAPE  = </b><b><i>Enterococcus, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter spp.</i></b></p><p>Risk factors associated with inadequate antimicrobial therapy in patients with severe sepsis or septic shock patients who had documented bloodstream infection.</p