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recommendations on empirical antimicrobial therapy in
patients with unique clinical situations such as severe betalactam allergy or in the case of suspicion of a particular antimicrobial resistance mechanism, including ESBL production,
as in Supplement 1.22-25 Moreover, the antimicrobial stewardship and support team would prospectively follow every
patient to ensure proper implementation of guidelines and
provide additional recommendations in patients with risk
factors for antimicrobial resistance.
Guideline implementation is also projected to reduce
overall utilization of antipseudomonal agents. Prospective
monitoring by the antimicrobial stewardship and support
team to ensure appropriate de-escalation of antimicrobial
regimen based on bacterial identification and in vitro antimicrobial susceptibility testing results may also shorten the
duration of antipseudomonal therapy. Because the guidelines
provide reassurance to health care providers that monotherapy adequately covers ≥95% of bloodstream isolates, it is
expected that use of combination antimicrobial therapy may
also decline after implementation.
The current guidelines have limitations that may impact
implementation at other institutions. First, accurately defining the site of infection acquisition may be challenging in
patients with unknown or limited medical histories within the
local health care system. Second, because all recommended
regimens constitute beta-lactam antibiotics, mechanisms to
screen patients and recommend alternative therapy in those
with severe beta-lactam allergy are necessary. Finally, there
are potential risks of not providing initial adequate coverage
for P aeruginosa in noncritically ill patients with communityacquired BSI and ESBL-producing Enterobacteriaceae overall, particularly in settings with higher incidence of BSI due
to these resistant bacteria than the current population. The use
of more robust models to predict the risk of BSI due to P
aeruginosa and ESBL-producing Enterobacteriaceae has
been demonstrated to improve both the adequacy of empirical
therapy and antimicrobial utilization.16,26
In summary, the study provides suggested methods for
development of institutional management guidelines for
Gram-negative BSI based on site of acquisition, local antimicrobial susceptibility rates of bloodstream isolates, and acute
severity of illness. Implementation of these institutional
guidelines may improve the adequacy of empirical antimicrobial therapy for Gram-negative BSI while reducing utilization of broad-spectrum antimicrobial agents.
Authors' Note
The preliminary results of this study were presented in part at IDWeek;
October 2014; Philadelphia, PA, USA (Abstract No. 47023).

Acknowledgment
The authors thank Palmetto Health Antimicrobial Stewardship and
Support Team and Microbiology Laboratory in South Carolina,
USA, for their help in facilitating the conduct of this study.

Hospital Pharmacy 52(10)
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of
this article: P.B.B. served as a content developer and speaker for
Rockpointe Corporation and FreeCe.com.

Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
study received funding from the Grant in Aid Program at Palmetto
Health Richland in Columbia, SC, USA. Funding source had no
role in study design.

References
1. Goto M, Al-Hasan MN. Overall burden of bloodstream infection and nosocomial bloodstream infection in North America
and Europe. Clin Microbiol Infect. 2013;19:501-509.
2. Retamar P, Portillo MM, López-Prieto MD, et al. Impact of
inadequate empirical therapy on the mortality of patients with
bloodstream infections: a propensity score-based analysis.
Antimicrob Agents Chemother. 2012;56:472-478.
3. Cain SE, Kohn J, Bookstaver PB, Albrecht H, Al-Hasan
MN. Stratification of the impact of inappropriate empirical
antimicrobial therapy for Gram-negative bloodstream infections by predicted prognosis. Antimicrob Agents Chemother.
2015;59:245-250.
4. Shorr AF, Micek ST, Welch EC, Doherty JA, Reichley RM,
Kollef MH. Inappropriate antibiotic therapy in Gram-negative
sepsis increases hospital length of stay. Crit Care Med.
2011;39:46-51.
5. Brigmon MM, Bookstaver BP, Kohn J, Albrecht H, Al-Hasan
MN. Impact of fluoroquinolone resistance in Gram-negative
bloodstream infections on healthcare utilization. Clin Microbiol
Infect. 2015;21:843-849.
6. Pien BC, Sundaram P, Raoof N, et al. The clinical and prognostic importance of positive blood cultures in adults. Am J Med.
2010;123:819-828.
7. Sogaard M, Norgaard M, Dethlefsen C, Schonheyder HC.
Temporal changes in the incidence and 30-day mortality associated with bacteremia in hospitalized patients from 1992
through 2006: a population-based cohort study. Clin Infect Dis.
2011;52:61-69.
8. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious
Diseases Society of America and the Society for Healthcare
Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin
Infect Dis. 2007;44:159-177.
9. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance
definition of health care-associated infection and criteria for
specific types of infections in the acute care setting. Am J Infect
Control. 2008;36:309-332.
10. Friedman ND, Kaye KS, Stout JE, et al. Health care-associated bloodstream infections in adults: a reason to change the
accepted definition of community-acquired infections. Ann
Intern Med. 2002;137:791-797.
11. Cheong HS, Kang CI, Wi YM, et al. Clinical significance and
predictors of community-onset Pseudomonas aeruginosa bacteremia. Am J Med. 2008;121:709-714.

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