There definitely exists a seemingly huge chasm between the antibiotic stewardship camp and the "better cover it all" camp.
Unlike the scenario that you described, most patients will not arrive at our door step with cultures that have demonstrated an organism - in fact bugs circulating systemically are only "caught" and grown 40-60% of the time that they are present by some estimates. I don't know the statistics on what % of patients actually have more than 1 colonization/infection (multiple bugs) however. Second, if we are considering an inpatient, who is already on an anti-infective directed toward a specific organism, and the patient is worsening, it makes sense to consider broader coverage. I am not suggesting that I have the answer - antibiotic stewardship has 2 components however: 1. Reduction of the creation of resistant organisms - 1 dose of a BS antibiotic will not likely cause this 2. Reduction of cost - but calculate the cost of a sicker patient that has a longer LOS and possibly an ICU stay tacked on vs. the cost of a few doses of Zosyn. I think that this discussion is not over by any means, it is happening at the CMS level right now. The take home message is clear however; we have had statistically significant reduction of mortality from severe sepsis and septic shock over the history of the Surviving Sepsis Campaign as a result of the guidelines and recommendations created. I also know that an effective antibiotic is better than some random BS antibiotic. But the BS coverage is recommended in the first 3 hours of presentation of severe sepsis - until the organism can be identified or surmised. I guess I always resort to what I would choose for myself or loved one - This has been more of an editorial than an answer - but I have been thinking about this for quite some time. Let's just DO BOTH. Give the directed agent if you think that you know the organism, cover the patient with BS empirically per the guidelines and then use good antibiotic stewardship to de-escalate as soon as possible while still providing source control in the best possible way. Thanks, MARY ANN BARNES-DALY RN BSN CCRN DC | Clinical Performance Improvement Consultant Sutter Health - Office of Patient Experience | 2200 River Plaza Drive, Sacramento, CA 95833 Mobile 916.200.5604| Office 916.286.6717 | [email protected] "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete." ~R. Buckminster Fuller From: Sepsisgroups [mailto:[email protected]] On Behalf Of Gluckner, Rhonda Sent: Tuesday, October 20, 2015 6:00 AM To: [email protected] Subject: [Sepsis Groups] anbitiotic choice I have a question posed to me about antibiotic choices by one of our physicians. I apologize if this has already been asked, but there is so much confusion around certain aspects of this new metric. This scenario was presented to me: A patient arrives at the hospital (whether direct admit or through the ED) for admission to the hospital for positive blood cultures (previously drawn and results called to PCP) and the organism has been identified with sensitivities completed. If the sensitivities indicate an effective antibiotic that is not listed on the monotherapy, do we still have to administer the second antibiotic to fall in line with the metric despite what would obviously be over-use of an antibiotic and poor stewardship? I understand this scenario is probably not very realistic as one of the monotherapy antibiotics is probably going to be listed as an effective antibiotic on the sensitivities, but I was asked to pose this question to the group. Thanks everyone for you input! Rhonda Gluckner, BSN, RN Sepsis Coordinator, Mercy Health-Youngstown Co-Chair, Mercy Health Sepsis Management Advisory Team Office: 330.480.2935 Pager: 330.229.2035 Fax: 330.480.3177 [email protected]<mailto:[email protected]> CONFIDENTIALITY NOTICE: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
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