Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, Netherlands.
Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Medical Microbiology and Immunology, Meander MC, Amersfoort, Netherlands.
Eur J Intern Med. 2020 Aug;78:69-75. doi: 10.1016/j.ejim.2020.04.013. Epub 2020 Apr 25.
Non-adherence to antimicrobial guidelines in patients with bloodstream infection can result in undertreatment, overtreatment, or equivalent treatment, and could lead to suboptimal care. Our aim was to examine the association between non-adherence and appropriate coverage as well as to assess the impact of non-adherence on 30-day mortality.
We conducted a retrospective cohort study between 2012 and 2017 at a tertiary university hospital. Adult patients attending the emergency department with a bloodstream infection were included. Adherence was defined as guideline-recommended antibiotic therapy. Non-adherence was either undertreatment (too narrow-spectrum), overtreatment (too broad-spectrum), or equivalent treatment. Outcomes were appropriate coverage (i.e. antibiotic therapy that matches in vitro susceptibility of the isolated bacteria) and 30-day mortality.
We included 909 patients of whom 395 (43.5%) were treated adherently, 355 (39.1%) were undertreated, 87 (9.6%) were overtreated, and 72 (7.9%) received an equivalent treatment. Overtreated patients were more severely ill, whilst undertreated patients had more favorable patient characteristics. Overtreatment did not result in higher appropriate coverage, whereas undertreatment was associated with lower coverage (OR[95%CI]: 0.18 [0.12; 0.26]). Overtreatment and undertreatment were not associated with 30-day mortality.
Guideline adherence likely depends on disease severity, because overtreatment was more often observed in patients with high disease severity and undertreatment in less severely ill patients. Undertreatment was associated lower appropriate coverage but not with higher mortality. However, this can be the result of residual confounding . Overtreatment did not result in higher appropriate antibiotic coverage nor a survival benefit . Therefore, overtreatment seems not justifiable.
血流感染患者不遵守抗菌指南可能导致治疗不足、过度治疗或等效治疗，从而导致治疗效果不佳。我们的目的是研究不遵守与适当覆盖之间的关联，并评估不遵守对 30 天死亡率的影响。
我们在 2012 年至 2017 年期间在一家三级大学医院进行了回顾性队列研究。将在急诊科就诊的患有血流感染的成年患者纳入研究。依从性定义为指南推荐的抗生素治疗。不依从性为治疗不足（谱太窄）、过度治疗（谱太宽）或等效治疗。结果为适当覆盖（即与分离细菌的体外药敏相符的抗生素治疗）和 30 天死亡率。
我们纳入了 909 名患者，其中 395 名（43.5%）接受了依从性治疗，355 名（39.1%）治疗不足，87 名（9.6%）过度治疗，72 名（7.9%）接受了等效治疗。过度治疗的患者病情更严重，而治疗不足的患者具有更有利的患者特征。过度治疗并未导致更高的适当覆盖率，而治疗不足与较低的覆盖率相关（OR[95%CI]：0.18 [0.12；0.26]）。过度治疗和治疗不足与 30 天死亡率无关。
指南依从性可能取决于疾病严重程度，因为过度治疗更常见于病情严重的患者，而治疗不足更常见于病情较轻的患者。治疗不足与较低的适当覆盖率相关，但与较高的死亡率无关。然而，这可能是残余混杂的结果。过度治疗并未导致更高的适当抗生素覆盖率或生存获益。因此，过度治疗似乎没有道理。
