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Appropriateness of empirical antibiotic prescription for bloodstream infections in an emergency department from 2006 to 2018: impact of the spread of ESBL-producing Enterobacterales

Abstract

The spread of ESBL producers in the community may impact the management of patients with bloodstream infections (BSI) involving Enterobacterales in emergency departments. Thus, from 2006 to 2018, data for all BSI episodes involving Enterobacterales from the emergency department of a French teaching hospital were retrospectively included. Antimicrobial susceptibility test results and empirical antibiotic regimens were recorded. Treatment was considered as appropriate if all isolates were susceptible in vitro to at least one prescribed antibiotic. A total of 1369 BSI episodes in 1321 patients was included. Urinary tract infection was the main source of BSI (61%). The prevalence of ESBL producers increased from zero to 9.2/100 Enterobacterales BSI cases (p < 0.001), mainly Escherichia coli (6.9 cases/100 BSI in 2018); and no Klebsiella. Third-generation cephalosporins (3GC) were used most frequently (71.8%) and their use as monotherapy increased during the study period (p < 0.001). The rate of appropriate treatment decreased from 95.8 to 89.2% (p = 0.023). Appropriateness of treatment was greater using two drugs vs one (97.3% vs 89.3%, p < 0.001). Treatments with 3GC were appropriate in 92% and 98.3%, when used alone or with another antibiotic, respectively (p < 0.001). Among inappropriate treatments, 45% concerned 3GC, with 74.6% of them attributable to ESBL production. The spread of ESBL producers in the community had a direct impact on the rate of inappropriate empirical treatment. Local antimicrobial resistance monitoring is required to optimize the management of BSI in emergency departments.

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Source of bloodstream infection (BSI, in %) among 1369 episodes (in 1321 patients) diagnosed in the emergency department between 2006 and 2018

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Authors

Contributions

Study design: P. Grohs, D. Lebeaux, F. Compain; clinical data collection: M. Clemenceau, S. Ahmed-Elie, F. Compain; data analysis: P. Grohs; statistical analysis: A. Villefaillot; manuscript writing: P. Grohs, D. Lebeaux; manuscript review: F. Compain.

Corresponding author

Correspondence to Patrick Grohs.

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Ethics approval for retrospective studies

The study complied with confidentiality regulations and ethical standards, and, in agreement with French regulations, was approved by the institutional review board (CER-MIT no 2021–0101, RGPD no 20210430112615).

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All the participant has consented to the submission of the study to the journal.

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The authors have no relevant financial or non-financial interests to disclose.

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Clemenceau, M., Ahmed-Elie, S., Vilfaillot, A. et al. Appropriateness of empirical antibiotic prescription for bloodstream infections in an emergency department from 2006 to 2018: impact of the spread of ESBL-producing Enterobacterales. Eur J Clin Microbiol Infect Dis (2021). https://doi.org/10.1007/s10096-021-04351-x

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Keywords

  • Bacteremia
  • ESBL
  • Antimicrobial resistance
  • Antimicrobial treatment