The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection

Authors

  • Leibovici,

    1. Department of Medicine, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel,
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  • Shraga,

    1. Department of Medicine, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel,
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  • Drucker,

    1. Infectious Diseases Unit, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel,
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  • Konigsberger,

    1. Infectious Diseases Unit, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel,
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  • Samra,

    1. Microbiology Laboratory, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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  • Pitlik,

    1. Department of Medicine, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel,
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  • Pitlik

    1. Infectious Diseases Unit, Rabin Medical Center, Beilinson Campus, Petah-Tiqva; and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel,
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Head of Department MD Leibovici Department of Medicine E, Beilinson Hospital, Petah-Tiqva 49100, Israel (fax: 972 39376505; e-mail: leibovic@post.tau.ac.il).

Abstract

Abstract. Leibovici L, Shraga I, Drucker M, Konigsberger H, Samra Z, Pitlik SD (Rabin Medical Center, Petah-Tiqva, and Tel-Aviv University, Tel-Aviv, Israel). The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med 1998; 244: 379–86.

Objectives

To test whether empirical antibiotic treatment that matches the in vitro susceptibility of the pathogen (appropriate treatment) improves survival in patients with bloodstream infections; and to measure the improvement.

Design

Observational, prospective cohort study.

Setting

University hospital in Israel.

Subjects

All patients with bloodstream infections detected during 1988–94.

Interventions

None.

Main outcome measures

In-hospital fatality rate and length of hospitalization.

Results

Out of 2158 patients given appropriate empirical antibiotic treatment, 436 (20%) died, compared with 432 of 1255 patients (34%) given inappropriate treatment (P = 0.0001). The median durations of hospital stay for patients who survived were 9 days for patients given appropriate treatment and 11 days for patients given inappropriate treatment. For patients who died, the median durations were 5 and 4 days, respectively (P < 0.05), for both comparisons.

In a stratified analysis, fatality was higher in patients given inappropriate treatment than in those given appropriate treatment in all strata but two: patients with infections caused by streptococci other than Streptococcus gr. A and Streptoccocus pneumoniae (odds ratio (OR) of 1.0, 95% confidence interval (95% CI) 0.4–2.5); and hypothermic patients (OR = 0.9, 95% CI = 0.3–2.4). Even in patients with septic shock, inappropriate empirical treatment was associated with higher fatality rate (OR = 1.6, 95% CI = 1.0–2.7). The highest benefit associated with appropriate treatment was observed in paediatric patients (OR = 5.1, 95% CI = 2.4– 10.7); intra-abdominal infections (OR = 3.8, 95% CI = 2.0–7.1); infections of the skin and soft tissues (OR = 3.1, 95% CI = 1.8–5.6); and infections caused by Klebsiella pneumoniae (OR = 3.0, 95%  CI = 1.7–5.1) and S. pneumoniae (OR = 2.6, 95%  C = 1.1–5.9).

On a multivariable logistic regression analysis, the contribution of inappropriate empirical treatment to fatality was independent of other risk factors (multivariable adjusted OR = 1.6, 95% CI = 1.3–1.9).

Conclusion

Appropriate empirical antibiotic treatment was associated with a significant reduction in fatality in patients with bloodstream infection.

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