Limits...
Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis.

Marquet K, Liesenborgs A, Bergs J, Vleugels A, Claes N - Crit Care (2015)

Bottom Line: A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics.Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).

View Article: PubMed Central - PubMed

Affiliation: Hasselt University, Faculty of Medicine and Life Sciences, Agoralaan, Building D, Room C53, Diepenbeek, BE3590, Belgium. kristel.marquet@uhasselt.be.

ABSTRACT

Introduction: The aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes.

Methods: Medline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.

Results: In total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).

Conclusions: This systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Show MeSH

Related in: MedlinePlus

Forest plot showing the effectiveness of appropriateness empirical antibiotics in severe infections on in-hospital mortality.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4358713&req=5

Fig3: Forest plot showing the effectiveness of appropriateness empirical antibiotics in severe infections on in-hospital mortality.

Mentions: In total, 26 studies [8,12,19,21,22,33,34,36-44,46-48,50,51,54-57] reported mortality as an outcome variable in patients with severe infection treated with (I)AAT. However, the time span of mortality assessment varied from 28 [34,55] to 30 [12,19,21,38,39,43,44,46,47,56] to 60 [51] days to 12 weeks [8]. Eleven studies [22,33,36,37,40-42,48,50,54,57] assessed in-hospital mortality. Given methodological considerations, meta-analysis on the effect of AAT on 30-day mortality (n = 10) and in-hospital mortality (n = 11) was conducted separately (Table 3). Five [12,19,43,44,46] of the 10 studies reporting on 30-day mortality showed a significant lower mortality for patients treated with AAT compared with those treated with IAAT. Meta-analysis for 30-day mortality revealed an RR of 0.71 (95% CI 0.62 to 0.82; P <0.0001) in favor of AAT, without significant heterogeneity: Cochran’s Q = 11.37, 9 degrees of freedom (d.f.), P = 0.252; I2 = 20.8 (0% to 61%) (Figure 2). Of the 11 trials [22,33,36,37,40-42,48,50,54,57] included in the meta-analysis on in-hospital mortality, eight trials [33,40-42,48,50,54,57] yielded significant lower mortality ratios in patients receiving AAT. Meta-analysis for in-hospital mortality revealed that an RR of 0.67 (95% CI 0.56 to 0.80; P <0.0001) in favor of AAT. However, there was significant heterogeneity: Cochran’s Q = 74.45, 10 d.f., P <0.0001; I2 = 86.6 (77.8% to 91.9%) (Figure 3). Funnel plots displayed an asymmetrical pattern for in-hospital mortality but not for 30-day mortality studies. The results of the sensitivity analysis suggest that three studies contribute to residual heterogeneity; removing them from the meta-analysis would reduce variability between studies. However, because this did not affect the results, these studies were retained. Meta-regression revealed that study quality (Down and Black score) (P = 0.003), inclusion of a definition of appropriate antibiotic usage (P = 0.0194), and studies reporting outcome for sepsis (P = 0.0001) significantly influenced the meta-analysis on in-hospital mortality.Table 3


Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis.

Marquet K, Liesenborgs A, Bergs J, Vleugels A, Claes N - Crit Care (2015)

Forest plot showing the effectiveness of appropriateness empirical antibiotics in severe infections on in-hospital mortality.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4358713&req=5

Fig3: Forest plot showing the effectiveness of appropriateness empirical antibiotics in severe infections on in-hospital mortality.
Mentions: In total, 26 studies [8,12,19,21,22,33,34,36-44,46-48,50,51,54-57] reported mortality as an outcome variable in patients with severe infection treated with (I)AAT. However, the time span of mortality assessment varied from 28 [34,55] to 30 [12,19,21,38,39,43,44,46,47,56] to 60 [51] days to 12 weeks [8]. Eleven studies [22,33,36,37,40-42,48,50,54,57] assessed in-hospital mortality. Given methodological considerations, meta-analysis on the effect of AAT on 30-day mortality (n = 10) and in-hospital mortality (n = 11) was conducted separately (Table 3). Five [12,19,43,44,46] of the 10 studies reporting on 30-day mortality showed a significant lower mortality for patients treated with AAT compared with those treated with IAAT. Meta-analysis for 30-day mortality revealed an RR of 0.71 (95% CI 0.62 to 0.82; P <0.0001) in favor of AAT, without significant heterogeneity: Cochran’s Q = 11.37, 9 degrees of freedom (d.f.), P = 0.252; I2 = 20.8 (0% to 61%) (Figure 2). Of the 11 trials [22,33,36,37,40-42,48,50,54,57] included in the meta-analysis on in-hospital mortality, eight trials [33,40-42,48,50,54,57] yielded significant lower mortality ratios in patients receiving AAT. Meta-analysis for in-hospital mortality revealed that an RR of 0.67 (95% CI 0.56 to 0.80; P <0.0001) in favor of AAT. However, there was significant heterogeneity: Cochran’s Q = 74.45, 10 d.f., P <0.0001; I2 = 86.6 (77.8% to 91.9%) (Figure 3). Funnel plots displayed an asymmetrical pattern for in-hospital mortality but not for 30-day mortality studies. The results of the sensitivity analysis suggest that three studies contribute to residual heterogeneity; removing them from the meta-analysis would reduce variability between studies. However, because this did not affect the results, these studies were retained. Meta-regression revealed that study quality (Down and Black score) (P = 0.003), inclusion of a definition of appropriate antibiotic usage (P = 0.0194), and studies reporting outcome for sepsis (P = 0.0001) significantly influenced the meta-analysis on in-hospital mortality.Table 3

Bottom Line: A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics.Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).

View Article: PubMed Central - PubMed

Affiliation: Hasselt University, Faculty of Medicine and Life Sciences, Agoralaan, Building D, Room C53, Diepenbeek, BE3590, Belgium. kristel.marquet@uhasselt.be.

ABSTRACT

Introduction: The aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes.

Methods: Medline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.

Results: In total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).

Conclusions: This systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Show MeSH
Related in: MedlinePlus