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Delayed appropriate therapy more harmful than CRE diagnosis
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SAN DIEGO — Delayed appropriate antibiotic therapy and drug-resistant infections are both associated with increased mortality, hospital duration and hospital costs; however, researchers reported at IDWeek that delayed therapy may have a greater impact on outcomes than drug resistance.
“This study demonstrates the critical importance of early identification of patients at risk for delayed appropriate therapy (DAT) through the use of clinical criteria for risk stratification or rapid diagnostic tools,” Thomas Lodise, PharmD, PhD, professor at the Albany College of Pharmacy and Health Sciences, said during a presentation. “The findings also highlight the need to shift current treatment practices away from antibiotic escalation strategies that contribute to DAT and toward early, aggressive, appropriate therapy in patients at risk for [resistant] infections.”
Lodise and colleagues examined data from more than 50,000 patients hospitalized with a complicated urinary tract infection, a complicated intra-abdominal infection, hospital-associated pneumonia or a bloodstream infection between July 2011 and September 2014. Among them, 514 had carbapenem-resistant Enterobacteriaceae (CRE) and 16,414 received DAT, which the researchers defined as appropriate treatment administered more than 2 days after diagnosis.
A gradient effect was observed across the population, with poor outcomes occurring less often among patients without CRE who received timely therapy (reference group) and more often among those with CRE who received DAT, Lodise said. Specifically, patients with CRE who received DAT had a nearly fourfold increased risk for mortality or discharge to hospice (OR = 3.7; 95% CI, 3.5-3.9) and twice the amount of hospital costs ($25,506 vs. $9,875) compared with patients in the reference group. However, there was a stronger association between poor outcomes and DAT than CRE.
“What we see here is not much of a difference by CRE status,” Lodise said. “Rather, the thing that really separated the outcomes among these patients with Enterobacteriaceae infections was DAT.”
He reported that patients without CRE who received DAT had longer hospital stays (8.5 days vs. 5.1 days) and greater hospital costs ($21,828 vs. $11,539) than patients with CRE who received appropriate, timely therapy.
“I don’t know how many more studies we need to show that early therapy matters. We talk about stewardship. One of the fundamental pillars of stewardship is getting it right the first time,” Lodise said. “I think these data suggest that it’s delayed therapy driving worse outcomes — not the resistance.” – by Stephanie Viguers
Reference:
Lodise T, et al. Abstract 141. Presented at: IDWeek; Oct. 4-8, 2017; San Diego.
Disclosure: Lodise reports receiving fees and honorarium for being a consultant and scientific advisor for Allergan.