Antimicrobial therapeutic determinants of outcomes in cirrhotic patients with septic shock.
Hepatology. 2012 Jun 30;
Authors: Arabi YM, Dara SI, Memish Z, Al-Abdulkareem A, Tamim HM, Al-Shirawi N, Parrillo JE, Dodek P, Lapinsky S, Feinstein D, Wood G, Dial S, Zanotti S, Kumar A, Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group
Context: It is unclear whether practice-related aspects of antimicrobial therapy contribute to the high mortality of cirrhotic patients with septic shock. Objective: We examined the relationship between aspects of initial empiric antimicrobial therapy and mortality in cirrhotic patients with septic shock. Design, Setting and Patients: This was a nested cohort study within a large retrospective database of septic shock from 28 medical centers in Canada, United States, and Saudi Arabia by the Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group between 1996 and 2008. Intervention:We examined the impact of initial empiric antimicrobial therapeutic variables on the hospital mortality of cirrhotic patients with septic shock. Results: Among 635 cirrhotic patients with septic shock, the hospital mortality was 75.6%. Inappropriate initial empiric antimicrobial therapy was administered in 155 (24.4%) patients. The median time (interquartile range [IQR]) to appropriate antimicrobial administration was 7.3 hours (3.2-18.3). The use of inappropriate initial antimicrobials was associated with increased mortality [adjusted odds ratio (aOR) 9.5, 95% confidence interval (CI), 4.3-20.7] as was the delay in appropriate antimicrobials (aOR for each 1 hour increase 1.1, 95% CI 1.1-1.2). Among patients with eligible bacterial septic shock, a single rather than 2 or more appropriate antimicrobials was used in 226 (72.9%) and was also associated with higher mortality (aOR 1.8, 95% CI, 1.0-3.3). These findings were consistent across various clinically relevant subgroups. Conclusions: In cirrhotic patients with septic shock, inappropriate and delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality. Monotherapy of bacterial septic shock is also associated with increased mortality. The process of selection and implementation of empiric antimicrobial therapy in this high-risk group should be re-structured. (HEPATOLOGY 2012.).
PMID: 22753144 [PubMed - as supplied by publisher]