Wait until infection is confirmed before starting antimicrobials in ICU

By Sarah Guy, medwireNews Reporter

Delaying antimicrobial treatment of patients in the surgical intensive care unit (SICU) who have a suspected hospital-acquired infection does not increase the risk for mortality, and may even be associated with better outcomes than starting antimicrobials before culturing blood, say researchers.

Their 2-year study employed an aggressive treatment strategy in the SICU - starting treatment on suspicion of patient infection without waiting for confirmation - during 1 year and a conservative approach - waiting for objective findings to confirm an infection - during the second year.

The findings indicate that not only did SICU patients treated during the aggressive treatment year have significantly lower survival rates, but they also had a lower chance of being given the appropriate treatment initially and a prolonged treatment regimen overall compared with their peers treated during the year of conservative approach.

"Our data suggest that waiting until infection is confirmed might be at least an equivalent option to a more aggressive approach where antimicrobial treatment is begun when infection is merely suspected," say Robert Sawyer and colleagues from the University of Virginia in Charlottesville, USA.

A total of 762 patients were admitted to the SICU during the aggressive treatment approach, and 721 were admitted during the year of conservative treatment.

Mean time between fever and treatment initiation was significantly shorter with the aggressive treatment approach compared with the conservative, at 11.1 versus 35.2 hours, while conversely, the duration of treatment was significantly longer in patients treated aggressively, at 17.7 versus 12.5 hours.

Indeed, during the aggressive treatment year, 23% of 661 patients never diagnosed with an ICU-acquired infection were started on antimicrobial treatment, while just 5% of 621 patients treated during the conservative year were.

Overall, 40% of 247 patients with infections treated during the aggressive year died compared with 21% of 237 treated in the conservative year; this difference was significant note the authors in Lancet Infectious Diseases.

After adjustment for potential confounders, aggressive treatment was associated with a 2.5-fold increase in risk for death, they add.

Based on these results, the team hypothesizes that the microbiomic damage caused by 48-72 hours of potentially ineffective antimicrobial drugs at the start and end of treatment "outweighs any benefit of starting treatment before microbiological confirmation of infection."

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