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Clinical References: Empiric Antibiotic Therapy Guidelines

GUIDELINES FOR THE EMPIRIC USE OF ANTIBIOTICS IN ADULT PATIENTS

These are the 2005 guidelines for the empiric use of antibiotics at NewYork-Presbyterian Hospital–Columbia University Medical Center. These recommendations were developed by the NewYork-Presbyterian Hospital–Columbia University Medical Center's Division of Infectious Diseases, Department of Epidemiology, and Department of Pharmacy in response to the increasing use of broad-spectrum antibiotics, recent susceptibility trends specifically at the Columbia University Medical Center campus, and the need to preserve existing antibiotics due to the lack of new antibiotics targeting gram-negative resistant organisms in the pipeline.

Antibiotic resistance is a tremendous and ever-growing problem in today's hospitals. Organisms like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are reaching record levels of prevalence. In addition, the multi-drug resistance seen in many gram-negative organisms like Pseudomonas aeruginosa leaves few treatment options and poses an equally important concern. It is clear that antibiotic resistance is largely a consequence of the overutilization of antibiotic agents, both in the hospital and in the community setting. Use of certain antibiotic classes also leads to the more rapid development of resistance to that class over time (e.g. quinolones) or leads to the selection of multidrug-resistant organisms (e.g. broad spectrum cephalosporin use associated with extended-spectrum beta-lactamase (ESBL) producing organisms). It is estimated that 4.5 million pounds of antibiotics are used in humans each year. Studies have shown that antibiotic utilization in hospitals is frequently inappropriate, either in spectrum (too broad or too narrow) or in duration. This can have a detrimental effect on patient outcomes (morbidity and mortality), costs, and antibiotic resistance patterns. Recent efforts to optimize antibiotic use reported in the literature have focused on efforts to modify antibiotics routinely used, "de-escalation" therapy, and shorter treatment durations. These efforts have resulted in decreased total consumption of antibiotics and positive impacts on resistance patterns without compromising patient outcomes. More recently, the emergence of a multidrug-resistant Klebsiella pneumoniae in New York City hospitals and nursing homes has brought into the forefront the need for prudent, directed antibiotic therapy.

The recommendations presented here are an attempt to aid in more rational selection of antibiotics based on the most likely pathogens for a given infection and the susceptibility profiles of these pathogens that are specific to this institution. This document is not hospital policy but is meant to serve as general guidelines for the empiric use of antibiotics in the hospital setting. These guidelines are intended as a tool to help guide the initial management of patients' infections and are not meant to replace clinical judgment in each particular case. We recognize that antibiotic therapy must still be individualized based on a patient's severity of illness, comorbidities, culture history, antibiotic history, and immune status. Subsequently, therapy should be modified based on the patients' clinical status and the microbiology data obtained. In no way should these guidelines replace an Infectious Diseases consultation and, as such, Infectious Diseases should continue to be contacted with any questions or requests for formal consultations.