QUALITY STANDARD FOR THE TREATMENT OF BACTEREMIA

OBJECTIVE: The objective of this quality standard is to optimize the t reatment of bacteremia in hospitalized patients by ensuring that the a ntibiotic given is appropriate in terms of the blood culture susceptib ility of the pathogen. Although this standard may appear to be minimal in scope, it is needed because appropriate antimicrobial treatment is not given in 5% to 17% of cases. To implement the standard, physician s, pharmacists, and microbiologists will need to devise a coordinated strategy. OPTIONS: We considered criteria for appropriate dosing, most cost-effective selection, proper antibiotic levels in serum, least to xicity, narrowest spectrum, specific clinical indications, and optimal duration of treatment. All these criteria were rejected as the basis for the standard because they were too controversial and too difficult to be applied by a nonphysician chart reviewer. In contrast, the sele ction of an antibiotic to which the pathogen is sensitive is a non-con troversial criterion and easy for a chart reviewer to apply. OUTCOMES: The standard is designed to reduce the incidence of adverse outcomes of septicemia such as renal failure, prolonged hospitalization, and de ath. EVIDENCE: Several well-designed clinical trials without randomiza tion as well as case-controlled studies have confirmed the benefit of using an antibiotic that is appropriate in light of the susceptibility of the isolate in blood culture. Prospective, randomized, placebo-con trolled trials are not available. VALUES: Our premise is that the pres ence of bacteremia is a risk factor for serious adverse outcomes. We a lso believe that the administration of antibiotics must always be guid ed by the susceptibility report for the pathogen(s) obtained from bloo d cultures. This concern is more critical for pathogens from the blood than for those from most other body sites. We had evidence that susce ptibility reports for pathogens from positive blood cultures were not always used properly. We used group discussion to reach a consensus am ong the members of the Quality Standards Subcommittee. BENEFITS, HARMS , AND COSTS: Through the implementation of this standard, at least 5% of bacteremias could be treated more appropriately. An unknown number of deaths would likely be prevented, and mortality from bacteremia tre ated inappropriately would probably be reduced. The primary undesirabl e feature of the standard is an increased workload of pharmacists and microbiologists. RECOMMENDATIONS: Treatment of bacteremia with an anti biotic that is appropriate in terms of the pathogen's blood-culture su sceptibility is a minimal standard of care for all patients. VALIDATIO N. We consulted more than 50 experts in infectious diseases from the f ields of medicine, surgery, pediatrics, obstetrics and gynecology, nur sing, epidemiology, pharmacology, and government. In addition, the met hods for its implementation were reviewed by the American Society of H ospital Pharmacists and were tested by one of the members of the Quali ty Standards Subcommittee. SPONSORS: The Quality Standards Subcommitte e of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was compos ed of representatives of the IDSA (Drs. Gross and McGowan), the Societ y for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infe ction Society (Dr. Dellinger), the Pediatric Infectious Diseases Socie ty (Dr. Krause), the Centers for Disease Control and Prevention (Dr. M artone), the Obstetrics and Gynecology Infectious Diseases Society (Dr . Sweet), and the Association of Practitioners of Infection Control (M s. Barrett). Funding was provided by the IDSA and the other cooperatin g organizations. This standard is endorsed by the IDSA.