Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection

A quasi-experimental, before and after observational cohort study

Tjasa Hranjec, Laura H. Rosenberger, Brian Swenson, Rosemarie Metzger, Tanya Flohr, Amani D. Politano, Lin M. Riccio, Kimberley A. Popovsky, Robert G. Sawyer

Research output: Contribution to journalArticle

82 Citations (Scopus)

Abstract

Background: Antimicrobial treatment in critically ill patients can either be started as soon as infection is suspected or after objective data confirm an infection. We postulated that delaying antimicrobial treatment of patients with suspected infections in the surgical intensive care unit (SICU) until objective evidence of infection had been obtained would not worsen patient mortality. Methods: We did a 2-year, quasi-experimental, before and after observational cohort study of patients aged 18 years or older who were admitted to the SICU of the University of Virginia (Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was used: patients suspected of having an infection on the basis of clinical grounds had blood cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a conservative strategy was used, with antimicrobial treatment started only after objective findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses were by intention to treat. Findings: Admissions to the SICU for the first and second years were 762 and 721, respectively, with 101 patients with SICU-acquired infections during the aggressive year and 100 patients during the conservative year. Compared with the aggressive approach, the conservative approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%]; p=0·015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0·0095), and a shorter mean duration of therapy (12·5 days [SD 10·7] vs 17·7 [28·1]; p=0·0080). After adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation (APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the aggressive therapy group compared with the conservative therapy group was 2·5 (95% CI 1·5-4·0). Interpretation: Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected SICU-acquired infections does not worsen mortality and might be associated with better outcomes and use of antimicrobial drugs. Funding: National Institutes of Health.

Original languageEnglish (US)
Pages (from-to)774-780
Number of pages7
JournalThe Lancet Infectious Diseases
Volume12
Issue number10
DOIs
StatePublished - Oct 1 2012

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Critical Illness
Observational Studies
Intensive Care Units
Cohort Studies
Critical Care
Infection
Therapeutics
Mortality
Intention to Treat Analysis
APACHE
National Institutes of Health (U.S.)
Group Psychotherapy
Hospital Mortality
Pharmaceutical Preparations
Odds Ratio
Wounds and Injuries

All Science Journal Classification (ASJC) codes

  • Medicine(all)
  • Infectious Diseases

Cite this

Hranjec, Tjasa ; Rosenberger, Laura H. ; Swenson, Brian ; Metzger, Rosemarie ; Flohr, Tanya ; Politano, Amani D. ; Riccio, Lin M. ; Popovsky, Kimberley A. ; Sawyer, Robert G. / Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection : A quasi-experimental, before and after observational cohort study. In: The Lancet Infectious Diseases. 2012 ; Vol. 12, No. 10. pp. 774-780.
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Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection : A quasi-experimental, before and after observational cohort study. / Hranjec, Tjasa; Rosenberger, Laura H.; Swenson, Brian; Metzger, Rosemarie; Flohr, Tanya; Politano, Amani D.; Riccio, Lin M.; Popovsky, Kimberley A.; Sawyer, Robert G.

In: The Lancet Infectious Diseases, Vol. 12, No. 10, 01.10.2012, p. 774-780.

Research output: Contribution to journalArticle

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T1 - Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection

T2 - A quasi-experimental, before and after observational cohort study

AU - Hranjec, Tjasa

AU - Rosenberger, Laura H.

AU - Swenson, Brian

AU - Metzger, Rosemarie

AU - Flohr, Tanya

AU - Politano, Amani D.

AU - Riccio, Lin M.

AU - Popovsky, Kimberley A.

AU - Sawyer, Robert G.

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Y1 - 2012/10/1

N2 - Background: Antimicrobial treatment in critically ill patients can either be started as soon as infection is suspected or after objective data confirm an infection. We postulated that delaying antimicrobial treatment of patients with suspected infections in the surgical intensive care unit (SICU) until objective evidence of infection had been obtained would not worsen patient mortality. Methods: We did a 2-year, quasi-experimental, before and after observational cohort study of patients aged 18 years or older who were admitted to the SICU of the University of Virginia (Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was used: patients suspected of having an infection on the basis of clinical grounds had blood cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a conservative strategy was used, with antimicrobial treatment started only after objective findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses were by intention to treat. Findings: Admissions to the SICU for the first and second years were 762 and 721, respectively, with 101 patients with SICU-acquired infections during the aggressive year and 100 patients during the conservative year. Compared with the aggressive approach, the conservative approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%]; p=0·015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0·0095), and a shorter mean duration of therapy (12·5 days [SD 10·7] vs 17·7 [28·1]; p=0·0080). After adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation (APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the aggressive therapy group compared with the conservative therapy group was 2·5 (95% CI 1·5-4·0). Interpretation: Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected SICU-acquired infections does not worsen mortality and might be associated with better outcomes and use of antimicrobial drugs. Funding: National Institutes of Health.

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