Systematic review of the impact of appropriate versus inappropriate initial antibiotic therapy on outcomes of patients with severe bacterial infections
Introduction
Severe bacterial infections are associated with considerable mortality, morbidity and healthcare costs [1], [2], [3], [4]. Assessment of the appropriateness of antibiotic therapy can be performed by evaluating cultures of causative pathogens and their antimicrobial susceptibility, which typically takes at least 48–72 h [5]. The adoption of rapid diagnostic techniques to determine antimicrobial susceptibility can reduce therapeutic delay but is not currently routine practice. Consequently, physicians initiate antibiotic treatment before test results have confirmed the causative pathogen and its drug resistance pattern. Initiation of inappropriate antibiotic treatment is associated with higher mortality and longer hospital length of stay (LOS) [4]. These results have been observed in patients with pneumonia, with appropriate initial therapy resulting in higher survival rates, shorter hospital stay and lower healthcare costs [6,7].
We performed a systematic review to assess the impact of delayed appropriate antibacterial therapy on clinical outcomes (i.e. mortality, LOS, cost and treatment failure) of patients with community- and hospital-acquired severe bacterial infections. Here we focus on the impact of appropriate versus inappropriate initial therapy.
Section snippets
Methods
This systematic review was undertaken according to the principles in the Cochrane handbook as well as guidance published by the Centre for Reviews and Dissemination [8], [9]. The protocol was published in the PROSPERO database (CRD42018104669; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=104669).
Results
The literature searches yielded 10 800 unique records for screening. Of these, 10 320 studies were excluded after an assessment of the title and abstract. The full-texts of the remaining 480 articles were assessed against inclusion and exclusion criteria and 145 studies, reported in 147 records, were eligible for inclusion in the systematic review. Of these 145 studies, 114 reported a comparison between receiving appropriate versus inappropriate initial therapy (Fig. 1; Supplementary Table S3).
Discussion
It is widely acknowledged that the use of inappropriate empirical antibiotics for the treatment of severe infections is associated with poor patient outcomes and increased hospital costs [38], [39], [40], [41], [42], [43]. This systematic review assessed the impact of appropriate versus inappropriate antibiotic therapy on multiple outcomes including mortality rate, treatment failure or success, rate of clinical cure, hospital LOS and hospital costs. The findings demonstrated significantly lower
Conclusion
In summary, patients with severe bacterial infections, especially carbapenem-resistant infections, are often seriously ill and can deteriorate quickly. Increasing the availability of rapid diagnostics and thus the incidence of early appropriate antimicrobial therapy is essential in order to reduce rates of mortality and to improve outcomes for patients with severe bacterial infections. In turn, this approach will reduce LOS and healthcare costs, reducing the impact and burden of these
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2022, Journal of Infection and Public HealthCitation Excerpt :Generally, mortality in patients with CAP requiring hospitalization is 4–18 %, and it could be up to 50 % for critically ill patients requiring intensive care unit admission [5–8]. Similar to all types of acute bacterial infections, early and appropriate antibiotics are the key treatment for patients with pneumonia [8–11]. The appropriateness of antibiotic therapy is determined by the culture of causative pathogens and their antimicrobial susceptibility.
- 1
These two authors contributed equally to this work.