Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2023.03.003
Brazilian Journal of Anesthesiology
Original Investigation

Impact of withholding early antibiotic therapy in nonseptic surgical patients with suspected nosocomial infection: a retrospective cohort analysis

Impacto da suspensão precoce da antibioticoterapia em pacientes cirúrgicos não sépticos com suspeita de infecção nosocomial: uma análise de coorte retrospectiva

Estevão Bassi, Bruno Martins Tomazini, Bárbara Vieira Carneiro, Amanda Rodrigues de Oliveira Siqueira, Sara Rodrigues de Oliveira Siqueira, Thais Guimarães, Fernando da Costa Ferreira Novo, Edivaldo Massazo Utiyama, Paolo Pelosi, Luiz Marcelo Sá Malbouisson

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Abstract

Background

Systemic inflammatory responses mimicking infectious complications are often present in surgical patients.

Methods

The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion.

Results

Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05–1.37).

Conclusions

Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.

Keywords

Antimicrobial stewardship; Critical care; Prescription drug overuse; Sepsis; Septic shock

Resumo

Introdução

Respostas inflamatórias sistêmicas que mimetizam complicações infecciosas estão frequentemente presentes em pacientes cirúrgicos.

Métodos

O objetivo foi avaliar a associação entre a suspensão precoce da terapia antimicrobiana durante a investigação de diagnósticos alternativos e piores resultados em pacientes não sépticos com suspeita de infecção nosocomial em uma coorte retrospectiva de pacientes cirúrgicos gravemente enfermos. O início da antibioticoterapia dentro de 24 horas da suspeita de infecção foi definido como grupo da estratégia antibiótica empírica precoce (EAEP) e o início após 24 horas da suspeita ou não prescrição foi definido como grupo da estratégia antibiótica conservadora (EAC). O desfecho primário foi composto: morte, sepse ou choque séptico em 14 dias. Os principais critérios de exclusão foram sepse ou fonte evidente de infecção no momento da inclusão.

Resultados

Trezentos e quarenta pacientes foram elegíveis para inclusão (74% pacientes com trauma). Idade, sexo, motivo da internação, escore SAPS3, escore SOFA e uso de vasopressores ou ventilação mecânica não foram diferentes entre os grupos. No prazo de 14 dias após a inclusão, 100% (130/130) dos pacientes com EAEP receberam antibióticos em comparação com 57% (120/210) dos pacientes com EAC. Após ajuste para variáveis de confusão, não houve associação entre o desfecho primário e os grupos. Em uma análise post hoc de subgrupo incluindo apenas pacientes com infecção confirmada a posteriori (por culturas microbiológicas), o atraso no início da terapia antimicrobiana adequada foi independentemente associado ao desfecho primário (Odds Ratio = 1,19 por dia de atraso; IC 95% 1,05–1,37 ).

Conclusão

A suspensão precoce da antibioticoterapia empírica não foi associada à progressão da disfunção orgânica em 14 dias em pacientes cirúrgicos não sépticos com suspeita de infecção nosocomial sem origem óbvia.

Palavras-chave

Gestão antimicrobiana; Cuidados intensivos; Uso excessivo de medicamentos prescritos; Sepse; Choque séptico

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Submitted date:
08/20/2022

Accepted date:
03/14/2023

642ec9e5a95395491d62c253 rba Articles
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