Evaluation of clinical practice guidelines on outcome of infection in medical intensive care unit patients

All patients in a 20-bed medical intensive care unit (ICU) were prospective ly followed for a 3-month period (phase I, 158 patients/1248 patient days) to collect baseline data before implementation of practice guidelines for i nfection management and were compared with all patients in the same unit du ring a 4-month period after guideline implementation (phase II, 180 patient s/972 patient days). Total infections in phase I vs, phase II, respectively , were the following: lower respiratory tract infection (LRTI), 87 (55%) vs . 94 (52%); urinary tract infection (UTI), 35 (22%) vs. 41 (23%); and sepsi s of undetermined etiology, 25 (16%) vs. 29 (16%). There were no significan t differences in death (23% vs. 20%), cure or improvement of infection (54% vs. 57%), readmission to the unit (3.6% vs. 3.4%), hospital risk of death (mean, 29.7 vs. 30.3), predicted length of ICU stay (mean, 6.09 days vs. 5. 93 days) in phases I and II, respectively. APACHE III score (mean, 64.6 vs. 59.4; P = not significant) and length of ICU stay were higher (mean, 7.9 d ays vs. 5.4 days; P<.001) in phase I vs, phase II. Rates for nosocomial inf ection in phase I vs. II (per 1000 patient medical ICU days) were the follo wing: LRTI, 6.4 vs. 5.1; UTI, 4.0 vs. 4.1; soft tissue infection, 0.8 vs. 0 ; bacteremia, 0.8 vs. 2.0; and intravenous catheter infection, 0.8 vs. 1.0 (P = not significant). Costs of antibiotic acquisition were $548.0 per pati ent in phase I and $372.9 per patient in phase II (P <.001). Compliance wit h guideline recommendations was 84%. There were trends toward an increase i n the susceptibility of Pseudomonas aeruginosa to ceftazidime (82% to 95% s usceptible; P =.18) and imipenem (91% to 100% susceptible; P =.17) and of E nterobacter species (P =.04) to ceftazidime. In medical ICU patients in who m guidelines for management of infections were used, antibiotic costs and b acterial resistance both decreased without adversely affecting patient outc omes. This study has important implications for the management of infection s in ICU patients.