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Quality Standard for the Treatment of Bacteremia

Published online by Cambridge University Press:  02 January 2015

Peter A. Gross
Affiliation:
Hackensack Medical Center, Hackensack, and, New Jersey Medical School, Newark, New Jersey
Trisha L. Barrett
Affiliation:
Alta Bates Medical Center, Berkeley, California
E. Patchen Dellinger
Affiliation:
University of Washington Medical Center, Seattle, Washington
Peter J. Krause
Affiliation:
Hartford Hospital, Hartford, andthe University of Connecticut School of Medicine, Farmington, Connecticut
William J. Martone
Affiliation:
Hospital Infections Program, Centers for Disease Control and Prevention, Atlanta, Georgia
John E. McGowan
Affiliation:
Emory University School of Medicine, Atlanta, Georgia
Richard L. Sweet
Affiliation:
Magee Women's Hospital and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Richard P. Wenzel
Affiliation:
University of Iowa Hospitals and Clinics, Iowa City, Iowa

Abstract

Objective:

The objective of this quality standard is to optimize the treatment of bacteremia in hospitalized patients by ensuring that the antibiotic given is appropriate in terms of the blood culture susceptibility of the pathogen. Although this standard may appear to be minimal in scope, it is needed because appropriate antimicrobial treatment is not given in 5% to 17% of cases. To implement the standard, physicians, pharmacists, and microbiologists will need to devise a coordinated strategy.

Options:

We considered criteria for appropriate dosing, most cost-effective selection, proper antibiotic levels in serum, least toxicity, narrowest spectrum, specific clinical indications, and optimal duration of treatment. All these criteria were rejected as the basis for the standard because they were too controversial and too difficult to be applied by a nonphysician chart reviewer. In contrast, the selection of an antibiotic to which the pathogen is sensitive is a non-controversial criterion and easy for a chart reviewer to apply.

Outcomes:

The standard is designed to reduce the incidence of adverse outcomes of septicemia such as renal failure, prolonged hos-pitalization, and death.

Evidence:

Several well-designed clinical trials without randomization as well as case-controlled studies have confirmed the benefit of using an antibiotic that is appropriate in light of the susceptibility of the isolate in blood culture. Prospective, randomized, placebo-controlled trials are not available.

Values:

Our premise is that the presence of bacteremia is a risk factor for serious adverse outcomes. We also believe that the administration of antibiotics must always be guided by the susceptibility report for the pathogen(s) obtained from blood cultures. This concern is more critical for pathogens from the blood than for those from most other body sites. We had evidence that susceptibility reports for pathogens from positive blood cultures were not always used properly. We used group discussion to reach a consensus among the members of the Quality Standards Subcommittee.

Benefits, Harms, and Costs:

Through the implementation of this standard, at least 5% of bacteremias could be treated more appropriately. An unknown number of deaths would likely be prevented, and mortality from bacteremia treated inappropriately would probably be reduced. The primary undesirable feature of the standard is an increased workload of pharmacists and microbiologists.

Recommendations:

Treatment of bacteremia with an antibiotic that is appropriate in terms of the pathogen's blood-culture susceptibility is a minimal standard of care for all patients.

Validation:

We consulted more than 50 experts in infectious diseases from the fields of medicine, surgery, pediatrics, obstetrics and gynecology, nursing, epidemiology, pharmacology, and government. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists and were tested by one of the members of the Quality Standards Subcommittee.

Sponsors:

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Diseases Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. This standard is endorsed by the IDSA.

Type
Consensus Paper
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1994

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References

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