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American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
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The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
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Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
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The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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Impact of Empirical Antibiotic Choice on the Clinical Outcomes of Patients Admitted to ICU with Sepsis and Septic Shock

Ihab B. Abdalrahman, Shaima N Elgenaid*, Galal Mohamedani, Mohammed Elfatih Ahmed Yousif

Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Abstract: Introduction: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to an infection. Sepsis is associated with high mortality rate. Early recognition and administration of appropriate empirical antibiotics therapy is associated with better outcomes; lower mortality rate and reduced length of stay. Objective: To assess the impact and appropriateness of empirical antibiotic choice on the clinical outcomes of sepsis and septic shock in intensive care department. Methods: The study included 53 patients admitted to Intensive Care Units. The type of empirical antibiotic was compared with the sensitivity profile of culture results. The clinical outcome was assessed as mortality or ICU discharges. Results: In this study, 58% of the patients were females and 50.9% were above 65 years. The most common risk factor for sepsis was recent hospitalization (32%) followed by diabetes mellitus (15%). The most common site of infection was the chest (34%). The majority of patients (81.1%) received combination empirical antibiotics. Patients who received appropriate empirical antibiotics had higher ICU discharge rates (P=0.001). Mortality rate was 67.9%; more than half of deaths (58%) occurred among patients with septic shock (P= 0.001). Conclusion: The use of appropriate empirical antibiotics in the management of sepsis and septic shock would result in better patient outcomes.

Keywords: admission, antibiotics, ICU, mortality, sepsis, septic shock, outcome

Received August 16, 2020; Revised September 19, 2020; Accepted September 28, 2020

Citation: Ihab B. Abdalrahman, Shaima N Elgenaid, Galal Mohamedani, Mohammed Elfatih Ahmed Yousif, Impact of Empirical Antibiotic Choice on the Clinical Outcomes of Patients Admitted to ICU with Sepsis and Septic Shock. American Journal of Educational Research, 8 (9). 727-730. January 2020. doi:10.12691/education-8-9-15

1. Introduction

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality [1]. Over the past four decades, the incidence of sepsis has substantially increased, the latest estimates in the United States, Europe and the United Kingdom range between 0.4/1000 and 1/1000 of the population [2,3,4,5,6]. Dagher et.al, reported the state of sepsis in the developing world between January 2008 and June 2012, they found that sepsis related deaths were around 40 % [7]. In Saudi Arabia they reported high majority in septic shock [8].

Hospital mortality for patients diagnosed with sepsis in the developed countries has decreased from 28% to 18% [3]. This big difference is related to early identification and early management [9]. This was related to implementation of sepsis bundle within one hour, which includes Measure lactate level, obtain blood cultures prior to administration of antibiotics, administer broad-spectrum antibiotics, rapidly administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 mmol/L, apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure ≥ 65 mm Hg [10].

Empiric broad-spectrum therapy with one or more intravenous antimicrobials to cover all likely pathogens should be started immediately for patients presenting with sepsis or septic shock and should be narrowed once pathogen identification and sensitivities are established [11]. High mortality was linked to delayed administration of antibiotics and with inappropriate antibiotics therapy [11,12].

In Sudan the incidence of sepsis is likely to be rising, data about sepsis and septic shock mortality is deficient. The lack of data about most common micro-organisms and antibiotic sensitivity patterns led to the deficiency of local empirical antibiotic guidelines. The aim of this study was to assess the impact and appropriateness of empirical antibiotic choice on the clinical outcomes of sepsis and septic shock in intensive care department.

2. Material and Methods

This is a cross-sectional hospital-based study, conducted in the ICU in Fedail specialized hospital (10 beds) and Aliaa specialized hospital (15 beds), Khartoum, Sudan, between 01/9/2018 to 30/10/ 2018. Data related to all Adult Patient (≥18-year-old) with sepsis and septic shock admitted to the ICU was collected. Data was abstracted and collected from the patients' records sheets in the hospital by structured questionnaire. The questionnaire covered patients' demographic data, reasons for admission, sepsis related risk factor, site of infection, timing of the blood culture sampling, culture result and administration of antibiotics. Hospital length of stay and mortality were measured.

Data analysis was managed using statistical package for social science (SPSS) for windows version 20. Chi-square test was used to test for significant difference between the variables. P. value < 0.05 was considered statistically significant. Ethical approval was obtained from the Sudan Medical Specialization Board (S.M.S.B). Confidentiality was maintained through using coded questionnaires. Permission was obtained from authorities in Fedail hospital and Aliaa hospital.

3. Results

Data was collected from 53 patients admitted to the ICUs. Females were 31 (58%) and 27 (50.9%) of the patients were older than 65 years as shown in (Table 1). sepsis and septic shock were reported in 30 (57%) and 23 (43%) of patient respectively.

Almost one third (34%) of patient has no identifiable risk factor. The most common risk factors were recent hospitalization within past 3 months (32%), diabetes mellitus (15%), cancer/chemotherapy (9%), chronic kidney disease (8%) and congestive heart failure (2%), (Table 2).

Respiratory tract infections were the most common source of infection (34%). While in 11.3% of patients, the site of infection was not identified. Other sites of infection included; urinary tract infection, 18.9%; abdomen, 15.1%; skin, 9.4%; central nervous system, 7.5% and intravenous catheter related sepsis was the least common, 3.8%. (Table 2)

Among the study population, 91% had a sample taken for culture and sensitivity; of them 52.8% were taken before starting of empirical antibiotics. In 22.6% were taken after receiving antibiotics, while in 24.5% there was no documented evidence of the timing of culture sample collection.

Most of the patients (81.1%) received a combination of empirical antibiotics compared to 18.9% who received single empirical antibiotic. More than one third (37%) of those who received combination empirical antibiotics were discharged from the ICU, compared to only 10% of those receiving single empirical antibiotic. This was not statistically significant, P= 0.097.

The culture results obtained from 48 patients showed 37 were positive and 11 were negative by the fifth day. Only 22% (n=8) of the culture results showed that the initial empirical antibiotic was sensitive, while the rest 78% (n=29) showed that the initial empirical antibiotic was not sensitive. Of the latter group the antibiotic was changed according to the culture results in 65.5% (n=19). The rates of discharge from hospital were 87.5% and 17.2% of patients in whom initial empirical antibiotic was sensitive and resistant respectively, P value was statistically significant, p = 0.001.

In the study population, 67.9% (n=36) of patients died in the ICU. Most of them suffered for septic shock in 58 % (n=21), P value = 0.001 and it was statistically significant (Table 3).

Table 1. Patient's demographic information and the cause of admission

Table 2. Risk factors for developing sepsis and documented sites of infection

Table 3. Association between patient's clinical condition and the patient's outcome

4. Discussion

In this study the majority of patients (50.9%) were older than 65 years; this result is consistent with other studies that put age as independent risk factor for developing sepsis and organ dysfunction [13]. Although one third of the patients (34%) have no identifiable risk factor, recent hospitalization was reported in 32% of patient. Hospitalization was reported to be associated with increased antibiotic resistant infections; this impact the selection of appropriated antibiotic [14,15]. Diabetes, congestive heart failure and chronic renal disease were found in one third of the study population. Sakr Y et al, reported that chronic illnesses, cancer therapy, mechanical ventilation, use of renal replacement therapy and infection with Acinetobacter are considered as independent risk factors for in-hospital death [16].

Respiratory tract infections were the most common site of infection (34%). Many studies found that respiratory tract infections are the most common site of infection, and associated with the highest mortality [17]. In this study the site of infection was not correlated to mortality. This can be explained by the lack of the effectiveness of empirical antibiotics in our study. Annane et al, analyzed data from 100,554 patients from 1993-2000, and found an increased trend in respiratory infection and multi-resistant bacterial related septic shock (P=0.001 for both) [18].

In quarter of patients there was no documented evidence of the timing of culture sample collection and this may reflect a poor documentation and the lack of the appropriate pathways for sepsis identification and management. Obtaining culture result is essential for definite diagnosis of sepsis and septic shock, having only clinical features without microbial documentation makes the diagnosis just likely [19]. Greig JR, reviewed the accuracy of documentation of blood culture results in a hospital in UK, he found that 26% of the reviewed results were not documented in the patient's records [20]. The use of appropriate antibiotics is associated with reduction in the mortality rate, but their adequacy will not be assured without antimicrobial documentation [21].

The use of combination antibiotics broadens the antibacterial spectrum of the empirical therapy [22]. Although our study had reported the use of combination empirical antibiotics in the majority of patients (81%), there was no significant relationship between the number of empirical antibiotic and mortality rates. This is different from results obtained by evaluation of 4664 cases of culture positive septic shock between 1996 and 2007, which had revealed decrease in hospital and ICU mortality with the use of combination therapy rather than monotherapy. In addition, there was increase in ventilator and inotrope/presser free days [23]. This is call for assessing the tools of appropriate empirical antimicrobial selection in our study.

According to our knowledge, Sudan lacks a national empirical antibiotic guideline; hospitals as well have no local empirical therapy guidelines. Therefore the choice of empirical antibiotic was not guided by a local sensitivity profiles. This resulted in only 24% of the culture results to be compatible with the initial empirical antibiotic. The majority (76%) showed that the initial empirical antibiotic was not sensitive. Patients received initial sensitive empirical antibiotic had higher ICU discharge and lower mortality rates compared to patients who received initial empirical antibiotic which was not sensitive on culture results.

The use of initial empirical antimicrobial therapy depends on the clinical presentation; therefore the usual way is to give broad spectrum therapy that targets the possible pathogens [24]. Moreover, there are many factors that influence the selection of the empirical therapy such as: site of infection, comorbidities, immune status and the local antimicrobial resistance [15,24]. While factors such as recent hospitalization and prior infection with resistant organism, should raise the need for antimicrobial therapy that covers MRSA and VRS [15]. In study done among 524 ICU patients, Buising KL et al, compared the initial antibiotic therapy with the microbiological lab results, they reported around 14% of sterile isolate and nearly one third of non-sterile isolate were associated with the use of inadequate empirical antimicrobial therapy against the identified bacteria [25].

In the study population 67.9% of patients died in the ICU, which is considered high compared to other studies [26]. The initial diagnosis of septic shock was associated with higher mortality compared to patients with sepsis (p less than 0.5). In some studies the mortality rate from septic shock reaches up to 50% [27].

5. Limitations

The study included only two hospitals and didn’t take into account the factor of delayed antibiotic administration, in addition to small sample size.

6. Conclusion

In conclusion, this study shows that the use of appropriate empirical antibiotics would result in better patient outcomes.

7. Recommendations

The study needs to be conducted in larger group of patients. Future studies should include the isolated micro-organisms and the sensitivity patterns.

References

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