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A Multicenter Evaluation of Prolonged Empiric Antibiotic Therapy in Adult ICUs in the United States*

Thomas, Zachariah PharmD1,2; Bandali, Farooq PharmD1,3; Sankaranarayanan, Jayashri MPharm, PhD4,5; Reardon, Tom MA6; Olsen, Keith M. PharmD, FCCP, FCCM4

doi: 10.1097/CCM.0000000000001294
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Objective: The purpose of this study is to determine the rate of prolonged empiric antibiotic therapy in adult ICUs in the United States. Our secondary objective is to examine the relationship between the prolonged empiric antibiotic therapy rate and certain ICU characteristics.

Design: Multicenter, prospective, observational, 72-hour snapshot study.

Setting: Sixty-seven ICUs from 32 hospitals in the United States.

Patients: Nine hundred ninety-eight patients admitted to the ICU between midnight on June 20, 2011, and June 21, 2011, were included in the study.

Intervention: None.

Measurements and Main Results: Antibiotic orders were categorized as prophylactic, definitive, empiric, or prolonged empiric antibiotic therapy. Prolonged empiric antibiotic therapy was defined as empiric antibiotics that continued for at least 72 hours in the absence of adjudicated infection. Standard definitions from the Centers for Disease Control and Prevention were used to determine infection. Prolonged empiric antibiotic therapy rate was determined as the ratio of the total number of empiric antibiotics continued for at least 72 hours divided by the total number of empiric antibiotics. Univariate analysis of factors associated with the ICU prolonged empiric antibiotic therapy rate was conducted using Student t test. A total of 660 unique antibiotics were prescribed as empiric therapy to 364 patients. Of the empiric antibiotics, 333 of 660 (50%) were continued for at least 72 hours in instances where Centers for Disease Control and Prevention infection criteria were not met. Suspected pneumonia accounted for approximately 60% of empiric antibiotic use. The most frequently prescribed empiric antibiotics were vancomycin and piperacillin/tazobactam. ICUs that utilized invasive techniques for the diagnosis of ventilator-associated pneumonia had lower rates of prolonged empiric antibiotic therapy than those that did not, 45.1% versus 59.5% (p = 0.03). No other institutional factor was significantly associated with prolonged empiric antibiotic therapy rate.

Conclusions: Half of all empiric antibiotics ordered in critically ill patients are continued for at least 72 hours in absence of adjudicated infection. Additional studies are needed to confirm these findings and determine the risks and benefits of prolonged empiric therapy in the critically ill.

1Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscatway, NJ.

2Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ

3Department of Pharmacy, Saint Peter’s University Hospital, New Brunswick, NJ.

4Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE.

5Department of Pharmacy Practice, School of Pharmacy, University of Connecticut/Hartford Hospital, Hartford, CT.

6Information and Technology Services, University of Nebraska Medical Center, Omaha, NE.

*See also p. 2675.

Current address for Dr. Thomas: Global Health Sciences, The Medicines Company, Parsippany, NJ.

Current address for Dr. Bandali: Medical Affairs, Janssen Scientific Affairs, Raritan, NJ.

Dr. Thomas consulted (attended advisory board meetings for rivaroxaban and Kcentra) and received support for the development of educational presentations (received honorarium for presenting for Rutgers sponsored Continuing Education presentation). Dr. Olsen received support for travel from the Society of Critical Care Medicine and the American College of Clinical Pharmacy. His institution received grant support from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: zachariah.thomas@gmail.com

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