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Stewardship / Resistance Scan for Sep 09, 2021

VA study finds faster receipt of antibiotics in sepsis patients

A study of US veterans hospitalized with community-acquired sepsis shows an overall decline in time-to-antibiotics, with significant variation across hospitals, researchers reported this week in JAMA Network Open.

The observational cohort study examined the time from presentation to antibiotic administration in sepsis patients admitted to 130 Veterans Affairs (VA) hospitals from 2013 to 2018. Faster receipt of antibiotics has been associated with improved survival in sepsis patients, and sepsis quality improvement programs have resulted in faster administration of antibiotics, but it’s unclear if antibiotic timing for sepsis has improved outside of formal performance incentive programs.

Among a total of 111,385 sepsis hospitalizations identified during the study period, 7,574 patients (6.8%) died in the hospital and 13,855 (12.4%) died within 30 days. Median time-to-antibiotics was 3.9 (2.4 to 6.5) hours, declining from 4.5 hours during 2013-2014 to 3.5 hours during 2017-2018—an absolute change of 54.6 minutes and a relative change of 22.2%. After adjusting for patient characteristics, median time-to-antibiotics declined by 9 minutes per year.

Analysis of hospital-level variation in time-to-antibiotics showed that the magnitude of decrease varied across hospitals, with hospitals that had faster baseline time-to-antibiotics experiencing less change over time. Hospitals in the slowest tertile decreased time to antibiotics by 16.6 minutes per year, while hospitals in the fastest tertile saw time-to-antibiotics decline by 7.2 minutes per year. Median time-to-antibiotics varied by 118.2% across hospitals during 2017-2018, ranging from 3.1 to 6.7 hours.

“This variation persisted after adjustment for granular patient characteristics, suggesting that sepsis practice patterns truly differ across hospitals,” the study authors wrote. “This may represent a potential opportunity for practice improvement going forward, but the benefits of further accelerating time-to-antibiotics must be balanced against the risk of driving antibiotic overuse in patients with noninfectious illness.”
Sep 7 JAMA Netw Open study


Trial data support shorter antibiotic course for bloodstream infections

The results of a randomized controlled trial conducted in Spain suggest that a 7-day course of antibiotics for Enterobacterales bloodstream infections (eBSIs) is preferable to 14 days, researchers reported yesterday in Clinical Microbiology and Infection.

The open-label, multi-center study enrolled patients diagnosed with eBSI from five Spanish hospitals to receive either 7 days (the experimental arm) or 14 days of antibiotic treatment (the control arm). Patients were followed for 28 days after stopping antibiotic treatment. The primary end point was days of treatment at the end of follow-up, and clinical outcomes were assessed through relapse of eBSI, relapse of fever, and clinical cure (resolution of all signs and symptoms of infection).

Secondary end points included crude mortality, superinfections, and adverse events. A superiority margin of 3 days was set for the primary end point, and a non-inferiority margin of 10% for clinical outcomes.

Of the 248 patients enrolled, 119 were assigned to 7 days of antibiotics and 129 to 14 days. The median length of antibiotic treatment in the intention-to-treat population was 7 days in the experimental arm and 14 in the control arm. No significant differences were observed for the other end points at the end of the 28-day follow-up, including mortality, relapse of eBSI, relapse of fever, superinfections, or drug-related adverse events. The non-inferiority margin was met for all clinical outcomes except relapse of fever, which was more frequent on the 7-day group (difference in absolute risk, —0.2%).

A Desirability of Outcome Ranking and Response Adjusted for Duration of Antibiotic Risk (DOOR/RADAR) analysis showed that patients receiving 7 days of treatment had a 77.7% greater probability of achieving better results compared with those who received 14 days of treatment.

The study authors say the findings on relapse of fever suggest some patients may need more than 7 days of antibiotics, but that the overall benefit of shorter antibiotic treatments is clear.

“In conclusion, this trial points to 7-day course of antibiotics as the preferential treatment for eBSI, as long as the source is properly controlled,” they wrote. “The potential impact of implementing this recommendation into clinical practice would be significant in the fight against bacterial resistance.”
Sep 8 Clin Microbiol Infect study

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