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.
Open accessAbstract
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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Potential harms of unnecessary antimicrobials include allergic or hypersensitivity reactions, kidney injury, thrombocytopenia, Clostridioides difficile infection, and antimicrobial resistance.
“These include a range of adverse events such as allergic or hypersensitivity reactions, kidney injury, thrombocytopenia, Clostridioides difficile infection, and antimicrobial resistance [101–106].”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [103]
Overly broad antibiotics are associated with similarly poor outcomes as inappropriately narrow antibiotics.
“Prior investigations suggest that overly broad antibiotics are associated with similarly poor outcomes as inappropriately narrow antibiotics.”
From Trends in empiric broad-Spectrum antibiotic use for suspected community-onset Sepsis in US hospitals (2024) · cites this paper as [40]
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- Authors
- Hranjec, T., Rosenberger, L. H., Swenson, B., Metzger, R., Flohr, T. R., Politano, A. D., Riccio, L. M., Popovsky, K. A., & Sawyer, R. G.
- Affiliations
- University of Virginia (US)
- Corresponding author
- Sawyer, Robert G
- Venue
- The Lancet Infectious Diseases
- Publisher
- Elsevier BV
- Published
- 2012-10
- Volume
- 12
- Issue
- 10
- Pages
- 774-780
- ISSN
- 1473-3099 (ISSN-L)
- PMC
- PMC3462590
- OpenAlex
- W2157720105
- Cited by
- 231
- References
- 32
- Citations by year
- 2026: 9 · 2025: 13 · 2024: 20 · 2023: 16 · 2022: 23 · 2021: 16 · 2020: 33 · 2019: 19 · 2018: 9 · 2017: 11 · 2016: 11 · 2015: 15 · 2014: 24 · 2013: 9 · 2012: 2
- FWCI
- 13.36
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet Infectious Diseases (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Health (T32AI78875-01A1)
- Topics
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
- Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Keywords
- intensive care unit-acquired infections, surgical intensive care unit, suspected infection, in-hospital mortality, antibiotic duration, blood culture, critically ill surgical patients, antimicrobial stewardship, APACHE II score, trauma patients, sepsis, pneumonia, surgical site infection, nosocomial infections
- MeSH terms
- Adult, Aged, Anti-Infective Agents, Critical Care, Cross Infection, Female, Humans, Male, Middle Aged, Prospective Studies, Time Factors, Confidence Intervals, Odds Ratio, Critical Illness, Hospital Mortality, APACHE, Intention to Treat Analysis
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