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. 2024 Jun 3;7(6):e2418923.
doi: 10.1001/jamanetworkopen.2024.18923.

Trends in Empiric Broad-Spectrum Antibiotic Use for Suspected Community-Onset Sepsis in US Hospitals

Chanu Rhee  1   2 , Tom Chen  1 , Sameer S Kadri  3   4 , Alexander Lawandi  3   5 , Christina Yek  3   4 , Morgan Walker  3   4 , Sarah Warner  3   4 , David Fram  6 , Huai-Chun Chen  6 , Claire N Shappell  7 , Laura DelloStritto  1 , Michael Klompas  1   2 ; CDC Prevention Epicenters Program
Affiliations

Trends in Empiric Broad-Spectrum Antibiotic Use for Suspected Community-Onset Sepsis in US Hospitals

Chanu Rhee et al. JAMA Netw Open. .

Abstract

Importance: Little is known about the degree to which suspected sepsis drives broad-spectrum antibiotic use in hospitals, what proportion of antibiotic courses are unnecessarily broad in retrospect, and whether these patterns are changing over time.

Objective: To describe trends in empiric broad-spectrum antibiotic use for suspected community-onset sepsis.

Design, setting, and participants: This cross-sectional study used clinical data from adults admitted to 241 US hospitals in the PINC AI Healthcare Database. Eligible participants were aged 18 years or more and were admitted between 2017 and 2021 with suspected community-onset sepsis, defined by a blood culture draw, lactate measurement, and intravenous antibiotic administration on admission.

Exposures: Empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) and/or antipseudomonal β-lactam agent use.

Main outcomes and measures: Annual rates of empiric anti-MRSA and/or antipseudomonal β-lactam agent use and the proportion that were likely unnecessary in retrospect based on the absence of β-lactam resistant gram-positive or ceftriaxone-resistant gram-negative pathogens from clinical cultures obtained through hospital day 4. Annual trends were calculated using mixed-effects logistic regression models, adjusting for patient and hospital characteristics.

Results: Among 6 272 538 hospitalizations (median [IQR] age, 66 [53-78] years; 443 465 male [49.6%]; 106 095 Black [11.9%], 65 763 Hispanic [7.4%], 653 907 White [73.1%]), 894 724 (14.3%) had suspected community-onset sepsis, of whom 582 585 (65.1%) received either empiric anti-MRSA (379 987 [42.5%]) or antipseudomonal β-lactam therapy (513 811 [57.4%]); 311 213 (34.8%) received both. Patients with suspected community-onset sepsis accounted for 1 573 673 of 3 141 300 (50.1%) of total inpatient anti-MRSA antibiotic days and 2 569 518 of 5 211 745 (49.3%) of total antipseudomonal β-lactam days. Between 2017 and 2021, the proportion of patients with suspected sepsis administered anti-MRSA or antipseudomonal therapy increased from 63.0% (82 731 of 131 275 patients) to 66.7% (101 003 of 151 435 patients) (adjusted OR [aOR] per year, 1.03; 95% CI, 1.03-1.04). However, resistant organisms were isolated in only 65 434 cases (7.3%) (30 617 gram-positive [3.4%], 38 844 gram-negative [4.3%]) and the proportion of patients who had any resistant organism decreased from 9.6% to 7.3% (aOR per year, 0.87; 95% CI, 0.87-0.88). Most patients with suspected sepsis treated with empiric anti-MRSA and/or antipseudomonal therapy had no resistant organisms (527 356 of 582 585 patients [90.5%]); this proportion increased from 88.0% in 2017 to 91.6% in 2021 (aOR per year, 1.12; 95% CI, 1.11-1.13).

Conclusions and relevance: In this cross-sectional study of adults admitted to 241 US hospitals, empiric broad-spectrum antibiotic use for suspected community-onset sepsis accounted for half of all anti-MRSA or antipseudomonal therapy; the use of these types of antibiotics increased between 2017 and 2021 despite resistant organisms being isolated in less than 10% of patients treated with broad-spectrum agents.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Rhee reported receiving royalties from UpToDate outside the submitted work. Mr Fram reported contract work from Harvard Pilgrim Healthcare Institute Department of Population Medicine contract during the conduct of the study. Dr H.-C. Chen reported contract work from Harvard Pilgrim Healthcare Institute Department of Population Medicine during the conduct of the study. Dr Klompas reported receiving royalties from UpToDate outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Microbiology of Suspected Community-Onset Sepsis
Resistant gram-positive organisms included methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), ceftriaxone-resistant Streptococcus, and methicillin-resistant coagulase-negative staphylococci (for blood cultures only). Resistant gram-negative organisms included P aeruginosa and any other ceftriaxone-resistant gram-negative pathogen.
Figure 2.
Figure 2.. Most Common Empiric Antibiotics Administered to Patients With Suspected Community-Onset Sepsis on Admission
MRSA indicates methicillin-resistant Staphylococcus aureus.
Figure 3.
Figure 3.. Fraction of Total Anti-MRSA and Antipseudomonal β-Lactam Therapy Accounted for by Patients With Suspected Community-Onset Sepsis
MRSA indicates methicillin-resistant Staphylococcus aureus.
Figure 4.
Figure 4.. Trends in Empiric Broad-Spectrum Antibiotic Use for Community-Onset Suspected Sepsis
MRSA methicillin-resistant Staphylococcus aureus.
See this image and copyright information in PMC

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