Journal
CLINICAL INFECTIOUS DISEASES
Volume 73, Issue 7, Pages 1231-1238Publisher
OXFORD UNIV PRESS INC
DOI: 10.1093/cid/ciab384
Keywords
antibiotic resistance; antimicrobial stewardship; deescalation
Categories
Funding
- Veterans Integrated Service Network 10 (VISN 10) Geriatric Research Education and Clinical Center at the Louis Stokes Cleveland Veterans Administration Medical Center
- National Institute of Allergy and Infectious Diseases of the National Institutes of Health [R01AI100560, R01AI063517, R21AI114508, R01AI072219, UM1AI104681]
- Veterans Health Administration Office of Research and Development [1I01BX001974]
- Veterans Administration Northeast Ohio Healthcare System
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The study used the DOOR MAT approach to evaluate antibiotic treatment of E. coli and K. pneumoniae bloodstream infections in VHA patients across a decade. Over the 10-year period, resistance to certain antibiotics increased in E. coli but remained stable in K. pneumoniae. Discrepancy between empiric and definitive treatment desirability narrowed, with no negative impact on patient survival.
Background. Reductions in the use of broad-spectrum antibiotics is a cornerstone of antimicrobial stewardship. We aim to demonstrate use of the Desirability of Outcome Ranking Approach for the Management of Antimicrobial Therapy (DOOR MAT) to evaluate the treatment of Escherichia coli and Klebsiella pneumoniae bloodstream infections in patients from the Veterans Health Administration (VHA) across a decade. Methods. Using electronic records, we determined empiric and definitive antibiotic treatments, clinical characteristics, and 30-day mortality of patients with monomicrobial E. coli and K. pneumoniae bloodstream infections hospitalized in VHA medical centers from 2009 to 2018. Focusing on patients treated with parenteral beta-lactams and with available antibiotic susceptibility testing results, we applied a range of DOOR MAT scores that reflect the desirability of antibiotic choices according to spectrum and activity against individual isolates. We report trends in resistance and desirability of empiric and definitive antibiotic treatments. Results. During the 10-year period analyzed, resistance to expanded-spectrum cephalosporins and fluoroquinolones increased in E. coli but not in K. pneumoniae, while resistance to carbapenems and piperacillin-tazobactam remained unchanged. In 6451 cases analyzed, we observed improvements in DOOR MAT scores consistent with deescalation. Improvement in desirability of definitive treatment compared with empiric treatment occurred in 26% of cases, increasing from 16% in 2009 to 34% in 2018. Reductions in overtreatment were sustained and without negative impact on survival. Conclusions. DOOR MAT provides a framework to assess antibiotic treatment of E. coli and K. pneumoniae bloodstream infections and can be a useful metric in antimicrobial stewardship.
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