Inappropriate Antibiotic Prescribing: It's Complicated

Surgical Rounds®, August 2014,

The issue of inappropriate antibiotic prescribing, which increases duration of treatment and hospital length of stay, is complicated in the surgical suite.

Almost daily, articles and editorials urge physicians to address the problem of inappropriate antibiotic prescribing, which increases duration of antibiotic treatment and hospital length of stay. The issue also has created multidrug-resistant organisms, and increased mortality rates.

The media would lead the public to believe that this is an easy problem to correct, and that it can be rectified if prescribers draw a line in the sand and stay behind it. However, in the surgical suite, the issue is much more complicated. The possibility of surgical site infection and sepsis is a serious concern and as the nature of empiric therapy relies on experience or observation alone, error is possible.

Researchers from the University of Virginia in Charlottesville were interested in identifying independent risk factors associated with inappropriate, empiric antimicrobial therapy for the treatment of severe sepsis. Their retrospective analysis of a prospectively maintained database of all surgical/trauma patients admitted to a tertiary care center appears in the July 2014 issue of the Journal of Trauma and Acute Care Surgery.

The investigators analyzed data from 1996 to 2007, looking patients who developed postsurgical sepsis and they identified 2,855 patients who experienced 7,158 infections. Surgeons prescribed empiric antibiotics appropriately for 5,073 infections (2,258 patients or 71%). They selected inappropriate antibiotics in 2,085 infections (597 patients or 29%).

The authors found surgeons were more likely to use inappropriate agents in patients older than 54 years, recipients of blood product transfusion, or patients who acquired nosocomial infections, had APACHE II scores between 16 and 20, or had white blood cell counts between 13.4 and 18.8.

Infection site independently predicted inappropriate, empiric antimicrobial therapy. Pleura, wound, central nervous system, peritoneal, and catheter-associated infections were most likely to be associated with inappropriate prescribing.

Infection with E. cloacae, C. albicans, and C. glabrata was also associated with inappropriate empiric therapy. The authors suggest that these organisms often represent superinfection, and most patients involved had been treated with other antibiotics in the recent past.

In this facility, inappropriate empiric therapy was linked to longer length of stay and duration of antimicrobial use. However, it did not increase mortality.

The authors suggest that broadening coverage against resistant gram-positive organisms and developing rapid microbiologic assays with improved sensitivity and specificity will decrease inappropriate prescribing.