We often have these sorts of discussions in the UK, and antimicrobial stewardship is right at the forefront of our routine clinical work. There is a huge difference between empirical therapy and targeted therapy. We have a national campaign of “start smart then focus”, which requires some thought as to the source of sepsis.
A successful strategy has three key components: 1. A rapid and competent clinical assessment. As more and more prescribing becomes protocolised, the choice of empirical therapy should be based on the potential system(s) involved. I find a diagnosis of sepsis ?cause an unhelpful and vague diagnosis. Neutropaenic sepsis has its own care pathway. Some take the view that the “better cover it all” ethos described by Mary below is just lazy prescribing. which flies in the face of a robust stewardship programme. 2. Know your local epidemiology. I am responsible for producing regular updates to the local prescribing committee as to which bugs we are seeing in which syndrome as well as the antibiotic resistance patterns for bugs in different clinical samples. Vigilance in this case may help guide your empirical prescribing for certain syndromes. 3. The first dose of antibiotic can be broad and certainly can help to save lives, but that isn’t the end of the story. Rapid diagnostics can now tell you what bug the patient has and the antibiotic sensitivity in 4-6 hours, which could target therapy before the next dose of antibiotics. I would certainly counsel against the idea of choosing random antibiotics. This will almost certainly cause the most patient harm and adversely affect the local ecology and resistance patterns. I think having a robust carbpanem sparing strategy is key, as these are our last line of defence against resistant bacteria. Kind regards, Abid. Dr Abid Hussain Consultant Microbiologist Director of Infection Prevention and Control Deputy Clinical Services Director, Clinical Lead for Microbiology PHE Public Health Laboratory, Birmingham and Honorary Senior Clinical Lecturer School of Clinical and Experimental Medicine University of Birmingham Heart of England Foundation Trust Birmingham Heartlands Hospital Bordesley Green East Birmingham B9 5SS UK [email protected] http://microblog.me.uk Follow me on Twitter @Microblog_me_uk and PHE on @PHE_UK From: "[email protected]<mailto:[email protected]>" <[email protected]<mailto:[email protected]>> on behalf of "Barnes-Daly, Mary Ann" <[email protected]<mailto:[email protected]>> Date: Wednesday, 21 October 2015 01:12 To: "'Gluckner, Rhonda'" <[email protected]<mailto:[email protected]>>, "'[email protected]<mailto:'[email protected]>'" <[email protected]<mailto:[email protected]>> Subject: Re: [Sepsis Groups] anbitiotic choice Warning: This message contains unverified links which may not be safe. You should only click links if you are sure they are from a trusted source. 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]<mailto:[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]<mailto:[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. _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
