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Table 3 Estimated effects of implementation of different empiric sepsis treatments on effective therapy rate and consumption of carbapenems in a population suspected of Gram-negative bacteremia

From: Using local clinical and microbiological data to develop an institution specific carbapenem-sparing strategy in sepsis: a nested case-control study

Treatment strategy

Sensitivity of the criterion for presence of combined resistance*

Proportion of patients with Gram-negative BSI adequately treated

Proportion of patients with Gram-negative BSI treated with carbapenem

Estimated NNTC** with carbapenem according to frequency of Gram-negative bacteremia in suspected sepsis

A priori probability of Gram-negative bacteremia in suspected sepsis a

 
    

5%

10%

20%

30%

40%

1. Cefuroxime/gentamicin in all patients with sepsis

0

.912

0

–

–

–

–

–

2. Carbapenem in all patients with sepsis

1.000

.998

1.000

233

116

58

39

29

3. Only a carbapenem in patients with antibiotic pre-treatment on day of culture.

.690

.971

.296

100

50

25

17

13

3. Only a carbapenem in patients with antibiotic treatment < 2 months

.943

.993

.529

130

65

33

22

16

4. Only a carbapenem in patients with a DRPb cultured < 6 months

.465

.952

.111

55

28

14

9

7

5. Only a carbapenem in patients with a DRP cultured previously (no time restriction)

.592

.963

.195

76

38

19

13

10

7. Only a carbapenem in patients with a DRP previously and antibiotic treatment < 2 months

.549

.961

.101

42

21

11

7

5

8. Current Practice

.225

.931

.056

57

29

14

10

7

  1. Legend A Frequency of Gram-negative bacteremia as percentage of the total No. of patients with suspected sepsis in whom empiric therapy is started. B Drug resistant pathogen(s) (DRP) isolated from any body site: Vancomycin resistant enterococci, multi resistant Staphylococcus aureus, Enterobacteriaceae with in vitro resistance to aminoglycosides, second and/or third generation cephalosporin’s (including ESBL positive Enterobacteriaceae) and/or quinolones, Pseudomonas aeruginosa with resistance to third generation cephalosporins, aminoglycosides or quinolones.* The sensitivity was derived from the study data (cases 2013–2016) ** NNTC = Number needed to treat with carbapenem instead of cefuroxime/gentamicin to avoid mismatch of empiric therapy for Gram-negative bacteremia in one patient. For the calculation of the NNTC the formula in Additional file 1: Supplement A was applied
  2. Example, strategy 5: Standard empiric treatment is cefuroxime/gentamicin, carbapenems are reserved for patients with a history of drug resistant pathogen (DRP). This results in prescription of a carbapenem in 19.5% of patients with Gram-negative bacteremia. With this strategy, empiric treatment of patients with cefuroxime/gentamicin resistant bacteremia is adequate in 59.2% and the overall treatment adequacy rate in Gram-negative bacteremia is 96.3%. In the scenario of a pre-test probability of Gram-negative bacteremia of 10%, 38 patients would be treated with a carbapenem to avoid mismatch of empiric therapy for Gram-negative bacteremia in 1 patient
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Antimicrobial Resistance & Infection Control

ISSN: 2047-2994

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