JAC Advance Access originally published online on October 3, 2007
Journal of Antimicrobial Chemotherapy 2007 60(6):1402; doi:10.1093/jac/dkm379
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Correspondence |
Comment on: Impact of antibiotic resistance and of adequate empirical antibiotic treatment in the prognosis of patients with Escherichia coli bacteraemia
1 Intensive Care Department, Ghent University Hospital, Ghent, Belgium 2 Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium 3 Faculty of Healthcare, University College Ghent, Ghent, Belgium 4 Infectious Diseases Department, Ghent University Hospital, Ghent, Belgium
* Correspondence address. Intensive Care Department, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. Tel: +32-9-240-62-16; Fax: +32-9-240-49-95; E-mail: stijn.blot{at}UGent.be
Keywords: bacteraemia , Escherichia spp. , antibiotic policy
We read with interest the article by Peralta et al.1 nicely outlining the relationships between multidrug resistance (MDR), decreased likelihood of appropriate empirical therapy and limited odds of survival. The authors concluded that continuing efforts should be aimed at earlier identification of patients with MDR Escherichia coli bacteraemia in order to administer them adequate empirical antimicrobial treatment. However, they did not suggest strategies to achieve this. With this letter, we would like to take the opportunity to share our experience of trying to increase the rate of appropriate empirical therapy. In our intensive care unit (ICU), routine microbiological surveillance cultures performed for infection control measures, such as detecting outbreaks, are also used to guide empirical therapy.2 Especially in late nosocomial infections in ICUs, the severity of underlying disease and acute illness substantially increases the toll of missing the causative pathogen at an early stage.3 Also, the high rates of MDR in ICUs complicate attempts to administer appropriate empirical therapy.4 We previously demonstrated that, although the associated mortality is high (34% to 44%), the attributable mortality of bacteraemia caused by Enterobacteriaceae can be limited to non-significant proportions.5–7 These favourable outcomes were, at least in part, achieved through a high rate of appropriate empirical therapy resulting from a strategy that takes into account the colonization status of the patient, as well as local ecology, and risk factors such as recent exposure to antibiotics and length of hospitalization. In critically-ill patients with either nosocomial pneumonia or bacteraemia, this approach proved to be valuable. In patients with bacteraemia caused by MDR Gram-negative bacteria, surveillance cultures predicted the causative aetiology in 75% of the episodes.8 In patients with bacteraemic pneumonia, tracheal surveillance cultures predicted the causative aetiology in 
70% of the cases.9 This was associated with higher rates of appropriate empirical therapy in comparison with what would have been achieved by following a strict empirical regimen recommended by the National Infectious Diseases Advisory Board.9 In addition, prediction of the causative aetiology was an independent predictor of better outcome as well.10 Furthermore, this surveillance-assisted approach limited the consumption of broad-spectrum antibiotics, thereby reducing microbial selection pressure and slowing down the emergence of MDR.9 As surveillance cultures are increasingly used in non-ICU settings, we believe that this might open doors towards an effective strategy for the prescription of empirical antibiotics in these settings as well.
None of the authors has received financial or other support in connection with this research.
References
1
Peralta G, Sánchez MB, Garrido JC, et al. Impact of antibiotic resistance and of adequate empirical antibiotic treatment in the prognosis of patients with Escherichia coli bacteraemia. J Antimicrob Chemother (2007) 60:855–63.
2 Blot S, Vandewoude K. Early detection of systemic infection. Acta Clin Belg (2004) 59:20–3.[Web of Science][Medline]
3 Kollef MH. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis (2000) 31(Suppl 4):S131–8.[CrossRef][Web of Science][Medline]
4 Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest (2000) 118:146–55.[CrossRef][Web of Science][Medline]
5 Blot S, Vandewoude K, Hoste E, et al. Absence of excess mortality in critically ill patients with nosocomial Escherichia coli bacteremia. Infect Control Hosp Epidemiol (2003) 24:912–5.[CrossRef][Web of Science][Medline]
6 Blot SI, Vandewoude KH, Colardyn FA. Clinical impact of nosocomial Klebsiella bacteremia in critically ill patients. Eur J Clin Microbiol Infect Dis (2002) 21:471–3.[CrossRef][Web of Science][Medline]
7 Blot SI, Vandewoude KH, Colardyn FA. Evaluation of outcome in critically ill patients with nosocomial Enterobacter bacteremia: results of a matched cohort study. Chest (2003) 123:1208–13.[CrossRef][Web of Science][Medline]
8 Blot S, Depuydt P, Vogelaers D, et al. Colonization status and appropriate antibiotic therapy for nosocomial bacteremia caused by antibiotic-resistant gram-negative bacteria in an intensive care unit. Infect Control Hosp Epidemiol (2005) 26:575–9.[CrossRef][Web of Science][Medline]
9 Depuydt PO, Blot SI, Benoit DD, et al. Antimicrobial resistance in nosocomial bloodstream infection associated with pneumonia and the value of systematic surveillance cultures in an adult intensive care unit. Crit Care Med (2006) 34:653–9.[CrossRef][Web of Science][Medline]
10 Depuydt P, Benoit D, Vogelaers D, et al. Outcome in bacteremia associated with nosocomial pneumonia and the impact of pathogen prediction by tracheal surveillance cultures. Intensive Care Med (2006) 32:1773–81.[CrossRef][Web of Science][Medline]
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