Hospital Pharmacy - November 2017 - 691

720506
research-article2017

HPXXXX10.1177/0018578717720506Hospital PharmacyNimmich et al

Article

Development of Institutional Guidelines
for Management of Gram-Negative
Bloodstream Infections: Incorporating
Local Evidence

Hospital Pharmacy
2017, Vol. 52(10) 691-697
© The Author(s) 2017
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https://doi.org/10.1177/0018578717720506
DOI: 10.1177/0018578717720506
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Elizabeth B. Nimmich1, P. Brandon Bookstaver2,3,
Joseph Kohn3, Julie Ann Justo2,3, Katie L. Hammer4,
Helmut Albrecht5,6, and Majdi N. Al-Hasan5,6

Abstract
Background: Appropriate empirical antimicrobial therapy is associated with improved outcomes of patients with Gramnegative bloodstream infections (BSI). Objective: Development of evidence-based institutional management guidelines for
empirical antimicrobial therapy of Gram-negative BSI. Methods: Hospitalized adults with Gram-negative BSI in 2011-2012
at Palmetto Health hospitals in Columbia, SC, USA, were identified. Logistic regression was used to examine the association
between site of infection acquisition and BSI due to Pseudomonas aeruginosa or chromosomally mediated AmpC-producing
Enterobacteriaceae (CAE). Antimicrobial susceptibility rates of bloodstream isolates were stratified by site of acquisition and
acute severity of illness. Retained antimicrobial regimens had predefined susceptibility rates ≥90% for noncritically ill and
≥95% for critically ill patients. Results: Among 390 patients, health care-associated (odds ratio [OR]: 3.0, 95% confidence
interval [CI]: 1.5-6.3] and hospital-acquired sites of acquisition (OR: 3.7, 95% CI: 1.6-8.4) were identified as risk factors
for BSI due to P aeruginosa or CAE, compared with community-acquired BSI (referent). Based on stratified bloodstream
antibiogram, ceftriaxone met predefined susceptibility criteria for community-acquired BSI in noncritically ill patients (95%).
Cefepime and piperacillin-tazobactam monotherapy achieved predefined susceptibility criteria in noncritically ill (95% both)
and critically ill patients with health care-associated and hospital-acquired BSI (96% and 97%, respectively) and critically ill
patients with community-acquired BSI (100% both). Conclusions: Incorporation of site of acquisition, local antimicrobial
susceptibility rates, and acute severity of illness into institutional guidelines provides objective evidence-based approach for
optimizing empirical antimicrobial therapy for Gram-negative BSI. The suggested methodology provides a framework for
guideline development in other institutions.
Keywords
bacteremia, sepsis, antibiotics, Escherichia coli, Enterobacter cloacae

Introduction
Bloodstream infections (BSI) have a significant impact on the
morbidity and mortality in the general population as nearly
500 000 individuals develop BSI annually in the United
States, contributing to 75 000 deaths.1 Adequate antimicrobial therapy is a key factor in reducing the burden of BSI, as
inadequate antimicrobial therapy has been associated with
increased mortality, cost, and length of stay in the hospital.2-5
Despite the extensive use of broad-spectrum antimicrobial
agents, it is alarming that 15% to 30% of patients with BSI
still receive inadequate empirical therapy.6,7
The initial selection of the empirical antimicrobial regimen in patients with Gram-negative BSI is a difficult task due
to lack of knowledge of the identification of the bloodstream
isolate and in vitro antimicrobial susceptibility results within

72 hours of presentation. Therefore, the development of local
guidelines for management of BSI may be an effective tool to
improve empirical antimicrobial therapy and hence patient
outcomes.1
1

Lexington Medical Center, West Columbia, SC, USA
College of Pharmacy, University of South Carolina, Columbia, USA
3
Palmetto Health Richland, Columbia, SC, USA
4
Carolinas HealthCare System, Charlotte, NC, USA
5
University of South Carolina School of Medicine, Columbia, USA
6
Palmetto Health USC Medical Group, Columbia, USA
2

Corresponding Author:
Majdi N. Al-Hasan, Associate Professor of Medicine, University of South
Carolina School of Medicine, 2 Medical Park, Suite 502, Columbia,
SC 29203, USA.
Email: majdi.alhasan@uscmed.sc.edu
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