In this episode, I’ll discuss whether delayed broad-spectrum antibiotics have an impact on clinical outcomes.
From my experience with antimicrobial stewardship efforts, the biggest reason for overly broad antibiotic coverage is what I call the “what if” factor. What if it really is Pseudomonas even though risk factors might not clearly indicate that broad coverage is needed? Overwhelmingly providers are much more inclined to broaden coverage if a “what if” possibility exists, likely because it seems like the risk of not covering a pathogen is higher than the risk of overly broad coverage.
However, a large retrospective study published in Clinical Infectious Diseases challenges that line of decision-making. A database that spans over 900 hospitals with almost three-quarters of a million inpatient encounters was analyzed to determine clinical outcomes in gram-negative infections after either empiric narrow-spectrum antibiotics escalated to broad-spectrum antibiotics (delayed broad-spectrum therapy) or empiric broad-spectrum antibiotics continued for at least 5 days (early broad-spectrum therapy).
Patients were matched based on hospital, diagnosis, and 28 clinical factors. Mortality was 8.7% with delayed broad-spectrum therapy but 9.5% with early broad-spectrum therapy. This difference was statistically significant and is counter to the desire to broaden empiric coverage “just in case”. Readmission rates were also significantly lower after delayed broad-spectrum therapy at 10.5% vs 11.8%, but adverse medication event rates were higher after delayed broad-spectrum therapy at 8.4% vs 7.2%.
The authors concluded:
On average, among a large sample of adult inpatients who ultimately received broad-spectrum antibiotic therapy, delaying initiation of a broad-spectrum antibiotic was not associated with worse outcomes. Though broad-spectrum empiric therapy is undoubtedly sometimes warranted, this finding challenges the common belief that is it safer to err towards overly broad-spectrum empiric antibiotic therapy.
While I am not convinced this one study will change how providers view the decision to broaden empiric therapy, hopefully it is the beginning of more studies that can chip away at this belief.
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