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Influence of Antibiotic Dose Adjustment on Mortality in Continuous Renal Replacement Therapy
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A1452 - Influence of Antibiotic Dose Adjustment on Mortality in Continuous Renal Replacement Therapy
Author Block: J. Stevens1, D. Hsu1, E. Smith2, T. Dechen1, J. Marshall1; 1Beth Israel Deaconess Medical Center, Boston, MA, United States, 2Cedars Sinai Medical Center, Los Angeles, CA, United States.
Rationale: Patients on antibiotic therapy prior to initiation of Continuous Renal Replacement Therapy (CRRT) often receive reduced antibiotic doses, but once CRRT is initiated, these renally-adjusted doses should be increased. While the exact dose required in these patients remains controversial due to the variety of CRRT methods, the initiation of CRRT leads to clinically significant increases in antibiotic elimination, and thus requires that the dose be increased. The purpose of this study was to identify the effect of antibiotic dose adjustments at CRRT initiation on mortality at a single institution, comparing patients who had doses increased within 12 hours versus those whose dose was never increased.
Methods: We conducted a single center, retrospective chart review of intensive care unit (ICU) patients initiated on CRRT between January 2010 and April 2014. Patients were included if they were > 18 years old and on renally-adjusted antibiotics. Patients were excluded if antibiotic therapy was prophylactic. The exposure of interest was whether any antibiotic dosing was changed after initiation of CRRT. The primary outcome was in-hospital mortality. Descriptive statistics were presented as proportions or means, with unvariable measures of association performed using chi-squared or Student’s t-test, as appropriate. Multivariable modeling was performed using logistic regression. We conducted a dummy exposure of adequate gastrointestinal prophylaxis, to identify whether patients who received adjusted antibiotic dosing had unmeasured confounding that indicated higher quality care.
Results: 234 patients were on dose-reduced antibiotics and required initiation of CRRT over this 4.25-year period. 68% (159/234) patients had their antibiotics adjusted during their ICU stay. Weekend or night-shift initiation of CRRT, severity of illness, and patient demographics were not significantly associated with the primary exposure. After adjustment, patients who failed to have their antibiotic dose increased with CRRT initiation were not at increased odds of death (aOR 1.4, 95% CI 0.8-2.5), although there was a trend towards harm. Use of adequate gastrointestinal prophylaxis was not associated with increased odds of death (aOR 0.4, 95% CI 0.04-3.3). In subgroup analyses restricted to patients treated with antibiotic therapy to which their infectious organisms were sensitive, failure to alter antibiotic dosing was significantly associated with in-hospital death in unadjusted analyses but not in adjusted analyses.
Conclusions: In a single academic medical center, critically ill patients with infections who underwent CRRT were not at increased risk of harm if antibiotic dosing was not changed in a timely way, although the study was likely underpowered.
Author Block: J. Stevens1, D. Hsu1, E. Smith2, T. Dechen1, J. Marshall1; 1Beth Israel Deaconess Medical Center, Boston, MA, United States, 2Cedars Sinai Medical Center, Los Angeles, CA, United States.
Rationale: Patients on antibiotic therapy prior to initiation of Continuous Renal Replacement Therapy (CRRT) often receive reduced antibiotic doses, but once CRRT is initiated, these renally-adjusted doses should be increased. While the exact dose required in these patients remains controversial due to the variety of CRRT methods, the initiation of CRRT leads to clinically significant increases in antibiotic elimination, and thus requires that the dose be increased. The purpose of this study was to identify the effect of antibiotic dose adjustments at CRRT initiation on mortality at a single institution, comparing patients who had doses increased within 12 hours versus those whose dose was never increased.
Methods: We conducted a single center, retrospective chart review of intensive care unit (ICU) patients initiated on CRRT between January 2010 and April 2014. Patients were included if they were > 18 years old and on renally-adjusted antibiotics. Patients were excluded if antibiotic therapy was prophylactic. The exposure of interest was whether any antibiotic dosing was changed after initiation of CRRT. The primary outcome was in-hospital mortality. Descriptive statistics were presented as proportions or means, with unvariable measures of association performed using chi-squared or Student’s t-test, as appropriate. Multivariable modeling was performed using logistic regression. We conducted a dummy exposure of adequate gastrointestinal prophylaxis, to identify whether patients who received adjusted antibiotic dosing had unmeasured confounding that indicated higher quality care.
Results: 234 patients were on dose-reduced antibiotics and required initiation of CRRT over this 4.25-year period. 68% (159/234) patients had their antibiotics adjusted during their ICU stay. Weekend or night-shift initiation of CRRT, severity of illness, and patient demographics were not significantly associated with the primary exposure. After adjustment, patients who failed to have their antibiotic dose increased with CRRT initiation were not at increased odds of death (aOR 1.4, 95% CI 0.8-2.5), although there was a trend towards harm. Use of adequate gastrointestinal prophylaxis was not associated with increased odds of death (aOR 0.4, 95% CI 0.04-3.3). In subgroup analyses restricted to patients treated with antibiotic therapy to which their infectious organisms were sensitive, failure to alter antibiotic dosing was significantly associated with in-hospital death in unadjusted analyses but not in adjusted analyses.
Conclusions: In a single academic medical center, critically ill patients with infections who underwent CRRT were not at increased risk of harm if antibiotic dosing was not changed in a timely way, although the study was likely underpowered.
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