Association Between the Sequence of β-lactam and Vancomycin Administration and Mortality in Patients with Suspected Sepsis.

Autor:	Kondo Y; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.; Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Bunkyo-Ku, Tokyo, JAPAN., Klompas M; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA., McKenna CS; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA., Pak TR; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA., Shappell CN; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA., DelloStritto L; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA., Rhee C; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Jazyk:	angličtina
Zdroj:	Clinical infectious diseases : an official publication of the Infectious Diseases Society of America [Clin Infect Dis] 2024 Dec 05. Date of Electronic Publication: 2024 Dec 05.
DOI:	10.1093/cid/ciae599
Abstrakt:	Background: Timely antibiotic initiation is critical to sepsis management, but there are limited data on the impact of giving β-lactams first vs vancomycin first amongst patients prescribed both agents. Methods: We retrospectively analyzed all adults admitted to 5 US hospitals from 2015-2022 with suspected sepsis (blood culture collected, antibiotics administered, and organ dysfunction) treated with vancomycin and a broad-spectrum β-lactam within 24h of arrival. We estimated associations between β-lactam vs vancomycin first strategies and in-hospital mortality using inverse probability weighting (IPW) to adjust for potential confounders. Results: Amongst 25,391 patients with suspected sepsis, 21,449 (84.4%) received β-lactams first and 3,942 (15.6%) received vancomycin first. Compared to the β-lactam first group, patients administered vancomycin first tended to be less severely ill, had more skin/musculoskeletal infections (20.0% vs 7.8%), and received β-lactams a median of 3.5h later relative to ED arrival. On IPW analysis, the β-lactam first strategy was associated with lower mortality (aOR 0.89, 95% CI 0.80-0.99). Point estimates were directionally similar but non-significant in a sensitivity analysis using propensity score-matching rather than IPW (aOR 0.94, 95% CI 0.82-1.07) and in subgroups of patients with positive blood cultures, MRSA cultures, and those administered antipseudomonal β-lactams. Conclusion: Among patients with suspected sepsis prescribed vancomycin and β-lactam therapy, β-lactam administration before vancomycin was associated with a modest reduction in hospital mortality. These findings support prioritizing β-lactam therapy in most patients with sepsis but merit affirmation in randomized trials given the risk of residual confounding in observational analyses. (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)
Databáze:	MEDLINE
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