Treatment of Sepsis with New Program Deemed Success

Implementing a new program to treat sepsis immediately with more antibiotics proved to increase only one of four categories of antibiotic use in the hospital setting, according to a paper published in Clinical Infectious Diseases.

Investigators from Virginia Commonwealth University Health System wanted to determine the impact of Sepsis Bundle Core Performance Measure for hospitals participating in the Inpatient Quality Reporting (SEP-1). This project was launched by the Centers for Medicare and Medicaid Services (CMS) in October 2015 in response to rising incidence and rising costs for sepsis treatment in recent years. The study authors noted that in 2009, sepsis care costs totaled $15.4 billion and was the most expensive condition among inpatients.

One of the elements in this project was to initiate broad-spectrum antibiotics within 3 hours of diagnosis, which the study authors said has the possibility to increase both antibiotic use and Clostridioides difficile (C diff) infection. The study authors collected monthly data from adult patients from 111 participating hospitals and divided the data into 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/ multidrug-resistant [MDR] organisms, and anti-MRSA). The time before implementation (Oct. 2014 to Sept. 2015) was compared to the post-implementation period (Oct. 2015 to June 2017).

Across the study period, the investigators found that broad-spectrum agents for hospital-onset/ MDR organisms were the most commonly used. These antibiotics as well as overall usage of antibiotics had a small but statistically significant increase pre- and post-SEP-1 implementation, the study authors wrote, by 2.3% and 1.4%, respectively.

There were no statistically significant changes in the level pre and post-SEP-1 implementation for anti-MRSA agents, surgical infection prophylaxis, or broad-spectrum agents for community-acquired infection, the study authors reported. They also noted an “unexpected” finding: there was a 7.3% decrease in C diff infection rates immediately following the SEP-1 program implementation.

The study authors said they did not find any significant long-term changes in individual antibiotic groupings or overall antibiotic use before and after October 2015, the initiation of SEP-1. However, they said, there were significant and sizable immediate increases in antibiotic use, for all antibiotic categories as well as the overall use.

They found an 88.9% increase in the overall antibiotic use following implementation of SEP-1, plus individual antibiotic categories increasing from 64.7% (anti-MRSA agents) to 284% increase in antimicrobials for surgical prophylaxis.

Other study results showed similar trends, the study authors noted. Medicine wards observed between June 2011 and July 2014 showed that electronic sepsis treatment protocol led to an increased level change in broad-spectrum antibiotic use in the post-implementation period compared to pre-implementation. Additionally, those studies observed an increased rate of C diff infection.

The study authors said that contrastingly, their finding of decreased C diff was a surprise but the nature of their study did not allow for further explanation of the reasoning for such a finding. They hypothesized that since 2015, national rates of C diff infection have decreased, and their results may have simply followed the national slope.

One limitation the study authors described is that other studies have suggested up to 40% of patients admitted with a “‘diagnosis’ [Quotation marks contained in original.] of sepsis admitted to intensive care do not actually have an infection,” they wrote. This could lead to SEP-1 protocols where non-infected patients are being administered broad-spectrum antibiotics in an effort to meet the rigid 3-hour timeframe.

“The findings of this study support continuing observation of antibiotic utilization following SEP-1 implementation,” the study authors concluded. “Meeting the 3-hour antibiotic time to first antibiotic dose is an important element of SEP-1; however, these data suggest that antimicrobial stewardship programs should apply post-prescription audit and feedback strategies among sepsis patients to ensure that antibiotic de-escalation is occurring appropriately.”