Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients.
Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients.
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DOI：
10.1093/jacamr/dlad054
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发表时间：
2023-06
影响因子：
3.4
通讯作者：
中科院分区：
文献类型：
--
作者：
经验性革兰氏阴性抗生素经常根据新的信息而改变。为了告知抗生素管理，我们试图使用微生物检测结果之前已知的信息来确定抗生素变化的预测因素。我们进行了一项回顾性队列研究。生存时间模型用于评价与抗生素递增和递减（定义为开始治疗后5天内革兰氏阴性抗生素谱或数量分别增加或减少）相关的临床因素。 频谱分为窄频谱、宽频谱、扩展频谱和受保护频谱。Tjur's D统计量用于估计变量组的区分能力。2019年，2751969名患者在920家研究医院接受了经验性革兰氏阴性抗生素治疗。 6.5%发生抗生素递增，49.2%发生抗生素递减; 8.8%改为等效方案。当经验性抗生素为窄谱（HR 19.0相对于保护性; 95% CI：17.9-20.1）、广谱（HR 10.3; 95% CI：9.78-10.9）或超广谱（HR 3.49; 95% CI：3.30-3.69）时，更可能发生剂量递增。入院时存在脓毒症（HR 1.94; 95% CI：1.91-1.96）和尿路感染（HR 1.36; 95% CI：1.35-1.38）的患者比无这些综合征的患者更有可能接受抗生素递增。联合治疗（每种额外药物的HR为2.62; 95% CI：2.61-2.63）或窄谱经验性抗生素（相对于受保护药物的HR为1.67; 95% CI：1.65-1.69）更有可能发生降级。经验性方案的选择分别占抗生素递增和递减解释变异的51%和74%。经验性革兰氏阴性抗生素通常在住院早期减量，而递增则不常见。变化主要由经验性治疗的选择和感染综合征的存在驱动。
Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur’s D statistic was used to estimate the discriminatory power of groups of variables. In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9–20.1), broad-spectrum (HR 10.3; 95% CI: 9.78–10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30–3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91–1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35–1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61–2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65–1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
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影响因子：
11.8
作者：
Gupta, Kalpana;Hooton, Thomas M.;Soper, David E.
通讯作者：
Soper, David E.
影响因子：
11.8
作者：
Claeys, Kimberly C.;Trautner, Barbara W.;Morgan, Daniel J.
通讯作者：
Morgan, Daniel J.
影响因子：
38.9
作者：
Giantsou, Elpis;Liratzopoulos, Nikolaos;Manolas, Konstantinos
通讯作者：
Manolas, Konstantinos
影响因子：
3
作者：
Elixhauser, A;Steiner, C;Coffey, RN
通讯作者：
Coffey, RN
DOI：
10.15585/mmwr.mm6945e2
发表时间：
2020-11-13
期刊：
MMWR. Morbidity and mortality weekly report
影响因子：
--
作者：
Lavery AM;Preston LE;Ko JY;Chevinsky JR;DeSisto CL;Pennington AF;Kompaniyets L;Datta SD;Click ES;Golden T;Goodman AB;Mac Kenzie WR;Boehmer TK;Gundlapalli AV
通讯作者：
Gundlapalli AV