eHealth and mHealth in Antimicrobial Stewardship to Reduce Mortality in Empirical Antimicrobial Therapy and a Systematic Review with a Meta-Analysis of Adequate Therapy

Abstract

The urgent requirement for swift diagnostic methods in pathogen identification and antimicrobial susceptibility testing is emphasized by rising bacterial resistance and limited treatment options, which are particularly critical in sepsis management. The shift from traditional phenotype-based methods to rapid molecular and mass spectrometry techniques has significantly reduced result turnaround times, enhancing patient outcomes. In this systematic review with meta-analysis, the aspects of correct empirical antimicrobial therapy are evaluated to determine their impact on mortality. We performed a systematic review and meta-analysis on EMBASE, the Cochrane Library, Web of Science, and MEDLINE. Studies evaluating mortality associated with empirical adequate and inadequate therapy in different sites of infection were included. Outcomes included clinical cures in microbiologically evaluable patients. Among the sites of infection, the most studied were bloodstream infections (n = 9), followed by respiratory tract infections (n = 5), intra-abdominal infections (n = 5), and urinary tract infections (evaluated by 3 studies). Inadequate therapy was associated with an increase in mortality between 11 and 68%. Technologies to speed up pathogen identification are extremely necessary to reduce mortality.

Keywords: antimicrobial resistance; antimicrobial stewardship; eHealth; mHealth; pharmacotherapeutic algorithms; rapid diagnostic methods.

Figure 1

Flow of clinical sample processing in the microbiology laboratory and approximate time for results. The arrows indicate potential test pathways, including direct molecular examination of clinical samples or analysis following growth on culture media. MALDI-TOF (matrix-assisted laser desorption ionization time-of-flight); AST (antimicrobial susceptibility test); ID (identification).

Figure 2

Flowchart of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality.

Figure 3

Forest plot of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality in different infection sites (abdominal, respiratory, urinary, bloodstream, and sepsis). * Patients admitted on intensive care unit. ** Patients admitted on ward [53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78].

Figure 4

Forest plot of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality in intra-abdominal infections. * Patients admitted on intensive care unit. ** Patients admitted on ward [65,69,73,78].

Figure 5

Forest plot of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality in bloodstream infections [56,58,60,61,68,74,75,77].

Figure 6

Forest plot of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality in respiratory tract infections. * Patients admitted on intensive care unit [54,57,62].

Figure 7

Forest plot of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality in urinary tract infections [55,63,70].

Figure 8

Forest plot of studies included in the meta-analysis to evaluate adequate antimicrobial therapy and mortality in sepsis [53,64,66,67,71,72].

Figure 9

Correlation between mortality and cumulative time of inadequate antibiotic (adapted from Kumar et al., 2006) [80].