Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen

Daisuke Furukawa; Thomas D Dieringer; Mitchell D Wong; Julia T Tong; Isa A Cader; Lauren E Wisk; Maria A Han; Summer M Gupta; Russell B Kerbel; Daniel Z Uslan; Christopher J Graber

doi:10.1017/ash.2021.232

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen

Antimicrob Steward Healthc Epidemiol. 2021 Dec 3;1(1):e59. doi: 10.1017/ash.2021.232. eCollection 2021.

Affiliations

¹ Division of Infectious Disease, Department of Medicine, University of California-Los Angeles, California.
² Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California.
³ David Geffen School of Medicine, University of California-Los Angeles, California.
⁴ Quality Management Services, UCLA Health, Los Angeles, California.
⁵ Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, California.

Abstract

Objective: To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution.

Design: Retrospective cohort study.

Setting: Two affiliated academic medical centers in Los Angeles, California.

Patients: Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards.

Methods: We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation.

Results: Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria.

Conclusions: Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.