Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically Ill Patients

doi:10.1378/chest.115.2.462

Chest

Volume 115, Issue 2, February 1999, Pages 462-474

https://doi.org/10.1378/chest.115.2.462 Get rights and content

Study objective

To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission.

Design

Prospective cohort study.

Setting

Barnes-Jewish Hospital, a university-affiliated urban teaching hospital.

Patients

Two thousand consecutive patients requiring admission to the medical or surgical ICU.

Interventions

Prospective patient surveillance and data collection.

Measurements and results

One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission.

Conclusions

Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.

Section snippets

Study Location and Patients

The study was conducted at a university-affiliated urban teaching hospital: Barnes-Jewish Hospital (1,400 beds) in St. Louis. During an 8-month period (July 1997 to March 1998), all patients admitted to the medical ICU (19 beds) and surgical ICU (18 beds) were potentially eligible for this investigation. Patients were excluded if they were transferred to the medical or surgical ICU temporarily due to a lack of available beds in one of the other hospital ICUs. The study was approved by the

Patients

A total of 2,000 consecutive eligible patients were prospectively evaluated (Table 1). The mean age of the patients was 57.7 ± 18.1 years (range, 13 to 105 years), and the mean APACHE II score was 15.2 ± 7.8 (range, 0 to 53). Nine-hundred forty-four (47.2%) patients were women and 1,056 (52.8%) were men. One thousand two-hundred seven (60.3%) patients were admitted to the ICU for a medical diagnosis, whereas 793 (39.7%) patients were admitted to the ICU following a surgical procedure.

Inadequate Antimicrobial Treatment of Infection

Discussion

We demonstrated a statistically significant association between the initial administration of inadequate antimicrobial treatment of infections and hospital mortality for adult patients requiring ICU admission. Multiple logistic regression analysis, controlling for potential confounding variables, demonstrated that the risk of hospital mortality was more than four times as great among infected patients receiving inadequate antimicrobial treatment compared with patients who did not possess this

Conclusion

In summary, we demonstrated that the occurrence of inadequate antimicrobial treatment of infections among patients requiring intensive care is an independent determinant of hospital mortality. Clinicians caring for critically ill patients should be aware of these findings since they suggest that specific clinical practices should be adopted in order to avoid treating patients with inadequate antimicrobial regimens. Our study also suggests that clinicians must be aware of the prevailing

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: Supported in part by grants from the Centers for Disease Control and Prevention (UR8/CCU715087) and Bayer Corporation.

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Chest

Clinical Investigations in Critical CareInadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically Ill Patients

Study objective

Design

Setting

Patients

Interventions

Measurements and results

Conclusions

Section snippets

Study Location and Patients

Patients

Inadequate Antimicrobial Treatment of Infection

Discussion

Conclusion

Crit Care Clinics

Chest

Chest

Chest

Am J Infect Control

Chest

Am J Med

Chest

Chest

Chest

Chest

Chest

Antimicrobial-drug resistance

N Engl J Med

The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of Infection in Intensive Care (EPIC) Study; EPIC International Advisory Committee

JAMA

Nosocomial pneumonia and mortality among patients in intensive care units

JAMA

Incidence, risk factors, and outcome of severe sepsis and septic shock in adults: a multicenter prospective study in intensive care units

JAMA

Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk

JAMA

Multiple organ failure: a common problem in surgical intensive care unit patients

Ann Med

The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia

Chest

Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group

Intensive Care Med

The value of routine microbial investigation in ventilator-associated pneumonia

Am J Respir Crit Care Med

Emergence of antibiotic-resistant bacteria in cases of peritonitis after intraabdominal surgery affects the efficacy of empirical antimicrobial therapy

Clin Infect Dis

Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy

Ann Intern Med

Mortality associated with nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus

Clin Infect Dis

Clinical Investigations in Critical Care
Inadequate Antimicrobial Treatment of Infections: A Risk Factor for Hospital Mortality Among Critically Ill Patients