Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

It is unclear whether practice-related aspects of antimicrobial therapy contribute to the high mortality from septic shock among patients with cirrhosis. We examined the relationship between aspects of initial empiric antimicrobial therapy and mortality in patients with cirrhosis and septic shock. This was a nested cohort study within a large retrospective database of septic shock from 28 medical centers in Canada, the United States, and Saudi Arabia by the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group between 1996 and 2008. We examined the impact of initial empiric antimicrobial therapeutic variables on the hospital mortality of patients with cirrhosis and septic shock. Among 635 patients with cirrhosis and septic shock, the hospital mortality was 75.6%. Inappropriate initial empiric antimicrobial therapy was administered in 155 (24.4%) patients. The median time to appropriate antimicrobial administration was 7.3 hours (interquartile range, 3.2-18.3 hours). The use of inappropriate initial antimicrobials was associated with increased mortality (adjusted odds ratio [aOR], 9.5; 95% confidence interval [CI], 4.3-20.7], as was the delay in appropriate antimicrobials (aOR for each 1 hour increase, 1.1; 95% CI, 1.1-1.2). Among patients with eligible bacterial septic shock, a single rather than two or more appropriate antimicrobials was used in 226 (72.9%) patients and was also associated with higher mortality (aOR, 1.8; 95% CI, 1.0-3.3). These findings were consistent across various clinically relevant subgroups. Conclusion: In patients with cirrhosis and septic shock, inappropriate and delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality. Monotherapy of bacterial septic shock is also associated with increased mortality. The process of selection and implementation of empiric antimicrobial therapy in this high-risk group should be restructured. (H epatology 2012;56:2305–2315)

Related collections

Most cited references 24

Record: found
Abstract: found
Article: not found

Health care--associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections.

N. Friedman, Keith S. Kaye, Jason Stout … (2002)

Bloodstream infections occurring in persons residing in the community, regardless of whether those persons have been receiving health care in an outpatient facility, have traditionally been categorized as community-acquired infections. To develop a new classification scheme for bloodstream infections that distinguishes among community-acquired, health care-associated, and nosocomial infections. Prospective observational study. One academic medical center and two community hospitals. All adult patients admitted to the hospital with bloodstream infection. Demographic characteristics, living arrangements before hospitalization, comorbid medical conditions, factors predisposing to bloodstream infection, date of hospitalization, dates and number of positive blood cultures, results of microbiological susceptibility testing, dates of hospital discharge or death, and mortality rates at 3 to 6 months of follow-up. 504 patients with bloodstream infections were enrolled; 143 (28%) had community-acquired bloodstream infections, 186 (37%) had health care-associated bloodstream infections, and 175 (35%) had nosocomial bloodstream infections. Of the 186 patients with health care-associated bloodstream infection, 29 resided in a nursing home, 64 were receiving home health care, 78 were receiving intravenous or intravascular therapy at home or in a clinic, and 117 had been hospitalized in the 90 days before their bloodstream infection. Cancer was more common in patients with health care-associated or nosocomial bloodstream infection than in patients with community-acquired bloodstream infection. Intravascular devices were the most common source of health care-associated and nosocomial infections, and Staphylococcus aureus was the most frequent pathogen in these types of infections. Methicillin-resistant S. aureus occurred with similar frequency in the groups with health care-associated infection (52%) and nosocomial infection (61%) but was uncommon in the group with community-acquired bloodstream infection (14%) (P = 0.001). Mortality rate at follow-up was greater in patients with health care-associated infection (29% versus 16%; P = 0.019) or nosocomial infection (37% versus 16%; P < 0.001) than in patients with community-acquired infection. Health care-associated bloodstream infections are similar to nosocomial infections in terms of frequency of various comorbid conditions, source of infection, pathogens and their susceptibility patterns, and mortality rate at follow-up. A separate category for health care-associated bloodstream infections is justified, and this new category will have obvious implications for choices about empirical therapy and infection-control surveillance.

0 comments Cited 429 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock.

Anand Kumar, Paul Ellis, Yaseen Arabi … (2009)

Our goal was to determine the impact of the initiation of inappropriate antimicrobial therapy on survival to hospital discharge of patients with septic shock. The appropriateness of initial antimicrobial therapy, the clinical infection site, and relevant pathogens were retrospectively determined for 5,715 patients with septic shock in three countries. Therapy with appropriate antimicrobial agents was initiated in 80.1% of cases. Overall, the survival rate was 43.7%. There were marked differences in the distribution of comorbidities, clinical infections, and pathogens in patients who received appropriate and inappropriate initial antimicrobial therapy (p < 0.0001 for each). The survival rates after appropriate and inappropriate initial therapy were 52.0% and 10.3%, respectively (odds ratio [OR], 9.45; 95% CI, 7.74 to 11.54; p < 0.0001). Similar differences in survival were seen in all major epidemiologic, clinical, and organism subgroups. The decrease in survival with inappropriate initial therapy ranged from 2.3-fold for pneumococcal infection to 17.6-fold with primary bacteremia. After adjustment for acute physiology and chronic health evaluation II score, comorbidities, hospital site, and other potential risk factors, the inappropriateness of initial antimicrobial therapy remained most highly associated with risk of death (OR, 8.99; 95% CI, 6.60 to 12.23). Inappropriate initial antimicrobial therapy for septic shock occurs in about 20% of patients and is associated with a fivefold reduction in survival. Efforts to increase the frequency of the appropriateness of initial antimicrobial therapy must be central to efforts to reduce the mortality of patients with septic shock.

0 comments Cited 341 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.

P Sort, M Navasa, V Arroyo … (1999)

In patients with cirrhosis and spontaneous bacterial peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. We randomly assigned 126 patients with cirrhosis and spontaneous bacterial peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in dosages that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. In patients with cirrhosis and spontaneous bacterial peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone.

0 comments Cited 266 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): Hepatology

Journal ID (iso-abbrev): Hepatology

Journal ID (publisher-id): hep

Title: Hepatology (Baltimore, Md.)

Publisher: Wiley Subscription Services, Inc., A Wiley Company (Hoboken )

ISSN (Print): 0270-9139

ISSN (Electronic): 1527-3350

Publication date (Print): December 2012

Publication date (Electronic): 04 December 2012

Volume: 56

Issue: 6

Pages: 2305-2315

Affiliations

[1 ]Intensive Care Department, King Abdulaziz Medical City Riyadh, Saudi Arabia

[5 ]Department of Hepatobiliary Surgery and Liver Transplantation, King Saud bin Abdulaziz University for Health Sciences King Abdulaziz Medical City, Riyadh, Saudi Arabia

[6 ]Department of Epidemiology and Biostatistics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City Riyadh, Saudi Arabia

[2 ]Department of Respiratory Services, King Abdulaziz Medical City Riyadh, Saudi Arabia

[3 ]Department of Infectious Diseases, Preventive Medicine Directorate, Ministry of Health Riyadh, Saudi Arabia

[4 ]College of Medicine, Alfaisal University Riyadh, Saudi Arabia

[7 ]Department of Medicine, Cooper Medical School of Rowan University Camden, NJ

[8 ]St. Paul's Hospital, University of British Columbia Vancouver, BC, Canada

[9 ]Section of Critical Care Medicine, Mount Sinai Hospital, University of Toronto Toronto, ON Canada

[10 ]Moses H. Cone Memorial Hospital Greensboro, NC

[11 ]Royal Jubilee Hospital/Victoria General Hospital, University of British Columbia Victoria, BC, Canada

[12 ]Section of Pulmonary Medicine, McGill University Montreal, QC, Canada

[13 ]Cooper Medical School of Rowan University Camden, NJ

[14 ]Department of Medical Microbiology and Pharmacology/Therapeutics, Section of Critical Care Medicine and Section of Infectious Diseases, Health Sciences Center and St. Boniface Hospital, University of Manitoba Winnipeg, MB, Canada

[15 ]Division of Cardiovascular Diseases and Critical Care Medicine, Cooper Medical School of Rowan University Camden, NJ

Author notes

Address reprint requests to: Yaseen M. Arabi, M.D., F.C.C.P., F.C.C.M., College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, P.O. Box 22490, Intensive Care Department, MC 1425, Riyadh, 11426, Saudi Arabia. E-mail: yaseenarabi@ 123456yahoo.com or icu1@ 123456ngha.med.sa ; fax: (966)-1-8011111 # 18880.

Potential conflict of interest: Anand Kumar received unrestricted research grants from Eli-Lilly, Pfizer, Bayer, Astellas, Merck, the Manitoba Health Research Council, the Health Sciences Centre (Winnipeg) Foundation, the Innovations and Opportunities Foundation (Winnipeg), and the Deacon Foundation (Winnipeg).

Additional and associate members of the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group are listed in the Appendix.

Article

DOI: 10.1002/hep.25931

PMC ID: 3556696

PubMed ID: 22753144

SO-VID: 4b5b4b37-a479-42fe-a9bd-0bfbfe5cfb9b

License:

Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit commercial exploitation.

Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis

Read this article at

Abstract

Related collections

Karger: Gastroenterology

Most cited references 24

Health care--associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections.

Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock.

Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis.

Author and article information

Journal

Affiliations

Author notes

Article

History

Categories

Comments

Comment on this article

Similar content 377

Cited by 41

Most referenced authors 1,195