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Cited by 1,805Antibiotic Use and ResistanceNosocomial Infections in ICUSepsis Diagnosis and Treatment

Inadequate Antimicrobial Treatment of Infections

Kollef, Marin H., Sherman, Glenda, Ward, Suzanne, Fraser, Victoria J.·1999·Chest
DOI 10.1378/chest.115.2.462
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Abstract

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.

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  • Prompt identification of invasive candidiasis through risk factor analysis and diagnostic assays is a key factor affecting sepsis-related mortality.

    “The importance of prompt identification of IC through a combination of risk factor analysis and diagnostic assays has been demonstrated to be a key factor affecting sepsis-related mortality.[32][33][34][35][36][37][38][39][40][41]”

    From Fungal Sepsis: Optimizing Antifungal Therapy in the Critical Care Setting (2011) · cites this paper as [32]

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Authors
Kollef, M. H., Sherman, G., Ward, S., & Fraser, V. J.
Affiliations
Barnes-Jewish Hospital (US)
Corresponding author
Kollef, Marin H.
ORCID
Venue
Chest
Publisher
Elsevier BV
Published
1999-02
Volume
115
Issue
2
Pages
462-474
ISSN
0012-3692 (ISSN-L)
DOI
10.1378/chest.115.2.462
OpenAlex
W2148706534
Cited by
1,805
References
52
Citations by year
2026: 12 · 2025: 24 · 2024: 25 · 2023: 27 · 2022: 38 · 2021: 33 · 2020: 35 · 2019: 50 · 2018: 49 · 2017: 57 · 2016: 59 · 2015: 69 · 2014: 99 · 2013: 64 · 2012: 93
FWCI
38.89
Type
journal article
Language
en
Open access
closed
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • CHEST Journal (publishedVersion)
  • PubMed (publishedVersion)
Funders
U.S. Public Health Service (UR8/CCU715087)
Topics
  • Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Nosocomial Infections in ICU
  • Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
Keywords
nosocomial infections, community-acquired infections, in-hospital mortality, intensive care unit patients, bloodstream infection, prior antibiotic use, APACHE II score, risk factors, infection-related mortality, antimicrobial stewardship, sepsis, surgical site infection, catheter-related infection, mortality prediction model, length of hospital stay
MeSH terms
Anti-Infective Agents, Critical Care, Cross Infection, Hospitals, Teaching, Humans, Intensive Care Units, Missouri, Prospective Studies, Risk Factors, Critical Illness, Treatment Outcome, Hospital Mortality, Treatment Failure, Community-Acquired Infections, APACHE

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