Table 2. Antimicrobial Prescribing and Outcomes by Year Among Patients Hospitalized With SIRS, Adjusted for Patient Characteristicsa.
| Outcome | 2013-2018 (n = 1 559 523) | 2013 (n = 259 754) | 2014 (n = 257 041) | 2015 (n = 256 729) | 2016 (n = 257 500) | 2017 (n = 265 163) | 2018 (n = 263 336) | P value for trend |
|---|---|---|---|---|---|---|---|---|
| Receipt of antimicrobial therapy | ||||||||
| Time to first antimicrobial, hb | ||||||||
| Median (IQR) | 4.4 (3.8-4.9) | 4.7 (4.0-5.2) | 4.7 (4.0-5.1) | 4.5 (3.8-5.0) | 4.4 (3.7-4.9) | 4.2 (3.6-4.8) | 4.1 (3.5-4.7) | <.001 |
| Mean (95% CI) | 4.3 (4.3-4.3) | 4.5 (4.5-4.5) | 4.4 (4.4-4.4) | 4.4 (4.3-4.4) | 4.3 (4.3-4.3) | 4.2 (4.2-4.2) | 4.1 (4.1-4.1) | <.001 |
| Antimicrobial, % | ||||||||
| Within 12 h | 49.8 | 49.1 | 49.4 | 49.7 | 50.0 | 50.2 | 50.5 | <.001 |
| Within 24 h | 56.0 | 55.9 | 55.9 | 55.9 | 56.0 | 56.0 | 56.0 | .24 |
| Within 48 h | 59.9 | 60.0 | 60.0 | 59.9 | 59.8 | 59.8 | 59.7 | .002 |
| Days of therapy to day 30, mean (95% CI) | 5.5 (5.5-5.5) | 5.8 (5.8-5.8) | 5.7 (5.7-5.7) | 5.6 (5.6-5.6) | 5.5 (5.4-5.5) | 5.3 (5.3-5.4) | 5.2 (5.2-5.2) | <.001 |
| Broadness of antibacterial coverage | ||||||||
| Receipt of broad-spectrum coverage, %c | ||||||||
| Within 48 h | ||||||||
| Spectrum Score ≥40 | 37.2 | 38.8 | 38.2 | 37.5 | 36.9 | 36.2 | 35.6 | <.001 |
| Spectrum Score ≥45 | 26.4 | 27.3 | 27.0 | 26.6 | 26.3 | 25.9 | 25.6 | <.001 |
| Within 30 d | ||||||||
| Spectrum Score ≥40 | 44.3 | 46.6 | 45.7 | 44.8 | 43.9 | 43.0 | 42.1 | <.001 |
| Spectrum Score ≥45 | 34.7 | 36.3 | 35.6 | 35.0 | 34.3 | 33.7 | 33.1 | <.001 |
| Cumulative Spectrum Score, mean (95% CI) | ||||||||
| 48 h | 23.7 (23.7-23.8) | 24.2 (24.2-24.3) | 24.0 (24.0-24.1) | 23.8 (23.8-23.9) | 23.6 (23.6-23.7) | 23.4 (23.4-23.5) | 23.2 (23.2-23.3) | .70 |
| 30 d | 27.3 (27.3-27.3) | 28.1 (28.1-28.2) | 27.8 (27.8-27.8) | 27.5 (27.4-27.5) | 27.2 (27.1-27.2) | 26.8 (26.8-26.9) | 26.5 (26.4-26.6) | <.001 |
| Outcomes | ||||||||
| Mortality, % | ||||||||
| In-hospital | 3.5 | 4.3 | 3.9 | 3.6 | 3.4 | 3.1 | 2.9 | <.001 |
| 30-d | 7.8 | 9.0 | 8.5 | 8.0 | 7.6 | 7.2 | 6.8 | <.001 |
| Length of stay, d | ||||||||
| Among all patients, median (IQR) | 5.8 (4.8-7.1) | 5.9 (5.0-7.1) | 5.9 (5.0-7.2) | 5.8 (4.9-7.1) | 5.8 (4.8-7.1) | 5.7 (4.7-7.0) | 5.5 (4.5-6.9) | <.001 |
| Patients with live discharge, median (IQR) | 5.7 (4.8-7.0) | 5.8 (5.0-7.0) | 5.8 (4.9-7.1) | 5.7 (4.8-7.0) | 5.7 (4.7-7.0) | 5.6 (4.6-6.9) | 5.5 (4.5-6.8) | <.001 |
| New antimicrobial resistance, % | ||||||||
| New MDR cultured | 2.9 | 3.8 | 3.4 | 3.0 | 2.7 | 2.4 | 2.2 | <.001 |
| New MDR blood cultured | 0.4 | 0.5 | 0.5 | 0.4 | 0.4 | 0.3 | 0.3 | <.001 |
Abbreviations: MDR, multidrug resistant; SIRS, systemic inflammatory response syndrome.
Outcomes in this table were estimated from linear or logistic regression models adjusted for age, sex, 30 Elixhauser comorbidities, individual SIRS criteria, and individual acute organ dysfunctions. Data for the 273 255 patients with sepsis are presented in eTable 4 in the Supplement.
Time to first antimicrobial use is reported for the 777 083 patients who received antimicrobial therapy within 12 hours.
A Spectrum Score of 40 or higher would include coverage with piperacillin-tazobactam (Spectrum Score, 42.25), vancomycin plus piperacillin-tazobactam (Spectrum Score, 44.5), or similar, whereas a Spectrum Score of 45 or higher would include coverage with vancomycin plus a carbapenem (Spectrum Score 45.25) or similar.
MDR is defined as a culture or swab positive for methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, carbapenem-resistant Enterobacteriaceae, extended-spectrum β-lactamase–producing Enterobacteriaceae, MDR Pseudomonas species (ie, a Pseudomonas species that is resistant to at least 1 antibacterial from at least 3 different antibacterial classes), or Acinetobacter, which was collected during calendar days 2 to 90 after emergency department arrival and no positive culture or swab for that organism in the 180 calendar days before emergency department arrival.