Antimicrobial treatment in patients with severe sepsis and septic shock: results from the German Prevalence Study

Objective

To determine the usage of antibiotic therapy for severe sepsis and septic shock in German ICUs.

Background

Appropriate antimicrobial therapy is one of the cornerstones in the treatment of severe sepsis and septic shock. Broad-spectrum antibiotics, as ureidopenicillins, fourth-class cephalosporins, carbapenems or fluorchinolons, are recommended agents for empirical antibiotic therapy. To date, nothing is known about how patients with severe sepsis and septic shock are actually treated in Germany.

Design and setting

A prospective observational cross-sectional 1-day-prevalence study from 15 January 2003 to 14 January 2004. A representative random sample of 310 hospitals with 454 ICUs out of a total of 1380 German hospitals with 2075 ICUs was obtained, forming five strata according to hospital size. Hospitals were visited by experienced ICU physicians from SepNet's 17 regional study centers.

Patients

From 3877 patients screened, 415 (11%) patients – representing a total of 1545 (95% CI, 1305–1786) daily patients in German ICUs – fulfilled the ACCP/SCCM criteria for severe sepsis or septic shock and were included in the analysis.

Results

The predominating origin of infection was respiratory tract infections (64%), followed by intra-abdominal infections (25.7%). Microbiological documentation was found in 57.3% of patients, 57.6% of whom had Gram-positive, 55.5% Gram-negative and 25.6% fungal infections; 9.6% of positive cultures were blood cultures. Less than 2% of patients had MRSA infections. Seven hundred and fifty-seven different antimicrobial agents were administered alone or in combination in the 415 patients with severe sepsis/septic shock on the study day: ureidopenicillins (12.0%), cephalosporins (12.6%), fluorchinolones (11.8%), carbapenems (10.4%), aminoglycosides (8.1%), glycopeptides (7.9%), metronidazole (8.2%), macrolides (4.5%), and antimycotics (9.8%). Of the antimicrobial prescriptions, 64.9% were administered empirically and 31.8% were microbiologically guided. Seventy-one (17.1.0%) patients received antimycotic treatment, but in only 11.6% were fungal isolates considered the likely cause of sepsis.

Conclusion

The usage of broad-spectrum antibiotics among patients with severe sepsis/septic shock is high in German ICUs, indicating that most patients probably receive appropriate antibiotic therapy. Aminoglycosides, which according to a recent meta-analysis [1] have been shown not to have additional benefit as an adjunct to broad spectrum-antibiotics, but rather renal side effects, have a rather low prescription rate. There may be an overuse of antimycotics, underlining the need for better diagnostic tools in patients colonized by fungi.