Empiric gram-negative antibiotic use is ‘inexplicably variable’ from hospital to hospital
Click Here to Manage Email Alerts
Empiric gram-negative antibiotic use varied significantly across the United States, with high inter-hospital variability, according to a recent study published in Clinical Infectious Diseases.
“Antibiotic resistance in gram-negative bacteria is an urgent public health threat, and we know that an important driver of resistance is unnecessary gram-negative antibiotic use, particularly of broad-spectrum antibiotics,” Katherine E. Goodman, JD, PhD, assistant professor in the department of epidemiology and public health at the University of Maryland School of Medicine, told Healio. “The challenge is that a lot of antibiotic use in hospitals occurs empirically — that is, before we know what type of antibiotic treatment a patient actually requires while awaiting microbiology and other test results.”
Goodman explained that, in these circumstances, much of the decision of whether to start patients on broad-spectrum antibiotics vs. narrow-spectrum antibiotics may come down to an individual clinician’s judgment, which she said, “carries the potential for a high degree of variability in how empiric antibiotics are being prescribed across U.S. hospitals.”
“Lacking large-scale tracking of empiric antibiotic use in this country, however, we’ve been blind to critical questions: How much empiric antibiotic use is actually occurring across U.S. hospitals, and how variable is it between hospitals? How much of it is broad-spectrum use specifically, and what are the patient and hospital factors that influence which type of antibiotics a patient will receive?” Goodman said. ‘The answers to these questions can identify targets for reducing unnecessary use of broad-spectrum empiric antibiotics and help ensure that patients who really need broad-spectrum empiric antibiotics still receive them.”
Goodman and colleagues performed a retrospective cohort study of adults discharged in 2019 from 928 hospitals in the Premier Healthcare Database. The researchers used multivariable logistic regression models with random effects by hospital to evaluate associations between patient and hospital characteristics and receipt of empiric broad-spectrum antibiotics compared with narrow-spectrum antibiotics for gram-negative infections.
Overall, 2,928,657 of 8,017,740 (37%) hospitalized adults received empiric gram-negative antibiotics. Among the 1,781,306 who received broad-spectrum therapy, 30% did not have a common infectious syndrome — such as pneumonia, UTI, sepsis or bacteremia — present at admission, surgery or an ICU stay in the empiric window.
“Strictly speaking, our study cannot say whether any of this use was unnecessary, but our data certainly shine a spotlight on the high usage that is occurring,” Goodman said.
The researchers also found that there were significant prescribing differences by region, with the highest adjusted odds of broad-spectrum therapy in the West South Central U.S. Goodman explained that if they assessed “two otherwise-equal patients who were admitted to two otherwise-equal hospitals and they both received empiric antibiotics,” the probability receiving broad-spectrum therapy could differ between them by 34 or more percentage points “solely due to their admitting hospital.”
“In other words, there were no obvious hospital or patient characteristics that could account for such divergent use of broad-spectrum antibiotics across different hospitals,” Goodman said.
Despite this, the study demonstrated that nonclinical factors, such as a patient’s sex and race, were associated with what type of antibiotic the patient received. For example, patients given empiric gram-negative antibiotics were 22% more likely to be male (adjusted OR = 1.22; 95% CI, 1.22-1.23) and that non-white racial groups were 6% to 13% less likely (aOR range = 0.87-0.94) to receive broad-spectrum therapy.
“The take-home message, in our view, is that there is a lot of empiric gram-negative antibiotic use occurring in U.S. hospitals,” Goodman said. “It is highly and inexplicably variable across hospitals, and there are potentially concerning disparities in how empiric antibiotics are being prescribed. On the one hand, these are concerning findings, but on the other hand, these findings are also motivating because they defy easy clinical explanation — that means empiric prescribing patterns and decisions may be modifiable.”
Collapse
Read more about
Click Here to Manage Email Alerts