Advertisement

Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit

Published:January 31, 2008DOI:https://doi.org/10.1016/j.ajic.2007.06.009

      Background

      Use of routine microbiologic surveillance, antibiotic practice guidelines, and infectious diseases (ID) specialist consultation might contribute to achieve an early diagnosis and an appropriate antibiotic treatment of infections, particularly in an intensive care unit (ICU) setting.

      Methods

      We conducted a prospective cohort study in an ICU over a period of 4 years (2001-2004). We studied all patients with a possible or definite diagnosis of infection who received antimicrobial treatment, analyzing the appropriateness of antimicrobial therapy prescription before (P1) and after (P2) the implementation (January 1, 2003) of a systematic ID specialist consultation program.

      Results

      Among the 349 patients enrolled, we observed 205 infections during P1 and 197 during P2. Infections treated with appropriate antimicrobial therapy were 141 (68.8%) in P1 and 165 (83.7%) in P2 (P .0004). Compliance to the local guidelines for empirical antimicrobial therapy increased by 20.4% from P1 to P2 (P < .0001). Patients receiving an appropriate treatment had a significantly shorter duration of antibiotic treatment (P < .0001), mechanical ventilation (P < .0001), ICU stay (P < .0001), and reduced in-hospital mortality (P = .006). Adherence to local antibiotic therapy guidelines improved significantly from P1 (63.4%) to P2 (83.8%) (P < .0001).

      Conclusion

      The introduction of an ID specialist consultation program may improve the appropriateness of the antimicrobial therapy prescription in ICU and the adherence to the local antibiotic therapy guidelines. Furthermore, appropriate antibiotic therapy is associated with a reduction in both ICU and in-hospital mortality.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Papazian L.
        • Bregeon F.
        • Thirion X.
        • Gregoire R.
        • Saux P.
        • Denis J.P.
        • et al.
        Effect of ventilator-associated pneumonia on mortality and morbidity.
        Am J Respir Crit Care Med. 1996; 154: 91-97
        • Bearman G.M.
        • Wenzel R.P.
        Bacteremias: a leading cause of death.
        Arch Med Res. 2005; 36: 646-659
        • Caplan E.S.
        • Hoyt N.
        Infection surveillance and control in the severely traumatized patient.
        Am J Med. 1981; 70: 638-640
        • Bueno-Cavanillas A.
        • Delgado-Rodriguez M.
        • Lopez-Luque A.
        • Schaffino-Cano S.
        • Galvez-Vargas R.
        Influence of nosocomial infection on mortality rate in an intensive care unit.
        Crit Care Med. 1994; 22: 55-60
        • Heyland D.K.
        • Cook D.J.
        • Griffith L.
        • Keenan S.P.
        • Brun-Buisson C.
        The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group.
        Am J Respir Crit Care Med. 1999; 159: 1249-1256
        • Rello J.
        • Quintana E.
        • Ausina V.
        • Castella J.
        • Luquin M.
        • Net A.
        • et al.
        Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients.
        Chest. 1991; 100: 439-444
        • Luna C.M.
        • Aruj P.
        • Niederman M.S.
        • Garzon J.
        • Violi D.
        • Prignoni A.
        • et al.
        Appropriateness and delay to initiate therapy in ventilator-associated pneumonia.
        Eur Respir J. 2006; 27: 158-164
        • Kumar A.
        • Roberts D.
        • Wood K.E.
        • Light B.
        • Parrillo J.E.
        • Sharma S.
        • et al.
        Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
        Crit Care Med. 2006; 34: 1589-1596
        • Alvarez-Lerma F.
        Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group.
        Intensive Care Med. 1996; 22: 387-394
        • Dupont H.
        • Mentec H.
        • Sollet J.P.
        • Bleichner G.
        Impact of appropriateness of initial antibiotic therapy on the outcome of ventilator-associated pneumonia.
        Intensive Care Med. 2001; 27: 355-362
        • Kollef M.H.
        • Sherman G.
        • Ward S.
        • Fraser V.J.
        Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.
        Chest. 1999; 115: 462-474
        • Lodise T.P.
        • McKinnon P.S.
        • Swiderski L.
        • Rybak M.J.
        Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia.
        Clin Infect Dis. 2003; 36: 1418-1423
        • Harbarth S.
        • Garbino J.
        • Pugin J.
        • Romand J.A.
        • Lew D.
        • Pittet D.
        Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis.
        Am J Med. 2003; 115: 529-535
        • Ibrahim E.H.
        • Sherman G.
        • Ward S.
        • Fraser V.J.
        • Kollef M.H.
        The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting.
        Chest. 2000; 118: 146-155
        • Fraser A.
        • Paul M.
        • Almanasreh N.
        • Tacconelli E.
        • Frank U.
        • Cauda R.
        • et al.
        Benefit of appropriate empirical antibiotic treatment: thirty-day mortality and duration of hospital stay.
        Am J Med. 2006; 119: 970-976
        • Leibovici L.
        • Shraga I.
        • Drucker M.
        • Konigsberger H.
        • Samra Z.
        • Pitlik S.D.
        The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection.
        J Intern Med. 1998; 244: 379-386
        • Michel F.
        • Franceschini B.
        • Berger P.
        • Arnal J.M.
        • Gainnier M.
        • Sainty J.M.
        • et al.
        Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures.
        Chest. 2005; 127: 589-597
        • Rosenthal V.D.
        • Guzman S.
        • Crnich C.
        Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals.
        Am J Infect Control. 2006; 34: 58-63
        • Rello J.
        • Gallego M.
        • Mariscal D.
        • Sonora R.
        • Valles J.
        The value of routine microbial investigation in ventilator-associated pneumonia.
        Am J Resir Crit Care Med. 1997; 156: 196-200
        • Delgado-Rodriguez M.
        • Gomez-Ortega A.
        • Sillero-Arenas M.
        • Martinez-Gallego G.
        • Medina-Cuadros M.
        • Llorca J.
        Efficacy of surveillance in nosocomial infection control in a surgical service.
        Am J Infect Control. 2001; 29: 289-294
        • Mead P.B.
        • Pories S.E.
        • Hall P.
        • Vacek P.M.
        • Davis Jr., J.H.
        • Gamelli R.L.
        Decreasing the incidence of surgical wound infections: validation of a surveillance-notification program.
        Arch Surg. 1986; 121: 458-461
        • Zolldann D.
        • Poetter C.
        • Hilker R.
        • Neveling M.
        • Waitschies B.
        • Klein W.
        • et al.
        Periodic surveillance of nosocomial infections in two neurology intensive care units: a valuable tool for quality management in intensive care.
        Der Anaesthesist. 2003; 52: 690-696
        • Zolldann D.
        • Thiex R.
        • Hafner H.
        • Waitschies B.
        • Lutticken R.
        • Lemmen S.W.
        Periodic surveillance of nosocomial infections in a neurosurgery intensive care unit.
        Infection. 2005; 33: 115-121
        • Haley R.W.
        • Culver D.H.
        • White J.W.
        • Morgan W.M.
        • Emori T.G.
        • Munn V.P.
        • et al.
        The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.
        Am J Epidemiol. 1985; 121: 182-205
        • Fowler Jr., V.G.
        • Sanders L.L.
        • Sexton D.J.
        • Kong L.
        • Marr K.A.
        • Gopal A.K.
        • et al.
        Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialists: experience with 244 patients.
        Clin Infect Dis. 1998; 27: 478-486
        • Roger P.M.
        • Hyvernat H.
        • Verleine-Pugliese S.
        • Bourroul C.
        • Giordano J.
        • Fosse T.
        • et al.
        Systematic infection consultation in the intensive care unit. Impact of short-term antibiotic use.
        Presse Med. 2000; 29: 1640-1644
        • Byl B.
        • Clevenbergh P.
        • Jacobs F.
        • Struelens M.J.
        • Zech F.
        • Kentos A.
        • et al.
        Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia.
        Clin Infect Dis. 1999; 29: 60-66
        • Fox B.C.
        • Imrey P.B.
        • Voights M.B.
        • Norwood S.
        Infectious disease consultation and microbiologic surveillance for intensive care unit trauma patients: a pilot study.
        Clin Infect Dis. 2001; 33: 1981-1989
        • Gomez J.
        • Conde Cavero S.J.
        • Hernandez Cardona J.L.
        • Nunez M.L.
        • Ruiz Gomez J.
        • Canteras M.
        • et al.
        The influence of the opinion of an infectious disease consultant on the appropriateness of antibiotic treatment in a general hospital.
        J Antimicrob Chemother. 1996; 38: 309-314
        • Lemmen S.W.
        • Hafner H.
        • Kotterik S.
        • Lutticken R.
        • Topper R.
        Influence of an infectious disease service on antibiotic prescription behavior and selection of multiresistant pathogens.
        Infection. 2000; 28: 384-387
        • Kollef M.H.
        Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients.
        Clin Infect Dis. 2000; 31: S131-S138
        • Levy M.M.
        • Fink M.P.
        • Marshall J.C.
        • Abraham E.
        • Angus D.
        • Cook D.
        • et al.
        2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
        Crit Care Med. 2003; 31: 1250-1256
        • Calandra T.
        • Cohen J.
        The international sepsis forum consensus conference on definitions of infection in the intensive care unit.
        Crit Care Med. 2005; 33: 1538-1548
        • WHO Collaborating Centre for Drug Statistics Methodology
        ATC index with DDDs and guidelines for ATC classification and DDD assignment.
        Norwegian Institute of Public Health, Oslo2006
        • Nathwani D.
        • Davey P.
        • France A.J.
        • Phillips G.
        • Orange G.
        • Parratt D.
        Impact of an infection consultation service for bacteraemia on clinical management and use of resources.
        QJM. 1996; 89: 789-797
        • Classen D.C.
        • Burke J.P.
        • Wenzel R.P.
        Infectious diseases consultation: impact on outcomes for hospitalized patients and results of a preliminary study.
        Clin Infect Dis. 1997; 24: 468-470
        • Garnacho-Montero J.
        • Garcia-Garmendia J.L.
        • Barrero-Almodovar A.
        • Jimenez-Jimenez F.J.
        • Perez-Paredes C.
        • Ortiz-Leyba C.
        Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis.
        Crit Care Med. 2003; 31: 2742-2751
        • Luna C.M.
        • Vujacich P.
        • Niederman M.S.
        • Vay C.
        • Gherardi C.
        • Matera J.
        • et al.
        Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.
        Chest. 1997; 111: 676-685
        • Kollef M.H.
        • Ward S.
        The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia.
        Chest. 1998; 113: 412-420
        • Capelastegui A.
        • Espana P.P.
        • Quintana J.M.
        • Gorordo I.
        • Ortega M.
        • Idoiaga I.
        • et al.
        Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design study.
        Clin Infect Dis. 2004; 39: 955-963
        • Dean N.C.
        • Bateman K.A.
        • Donnelly S.M.
        • Silver M.P.
        • Snow G.L.
        • Hale D.
        Improved clinical outcomes with utilization of a community-acquired pneumonia guideline.
        Chest. 2006; 130: 794-799
        • Dean N.C.
        • Silver M.P.
        • Bateman K.A.
        • James B.
        • Hadlock C.J.
        • Hale D.
        Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.
        Am J Med. 2001; 110: 451-457
        • Kollef M.H.
        • Fraser V.J.
        Antibiotic resistance in the intensive care unit.
        Ann Intern Med. 2001; 134: 298-314