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Table 1 7-step method for the development on institution specific empiric treatment guidelines

From: Using local clinical and microbiological data to develop an institution specific carbapenem-sparing strategy in sepsis: a nested case-control study

  Description Example
Step 1 The clinical question Define A) the clinical syndrome for which empiric treatment is re-evaluated, B) the patient population and C) the current empiric treatment guideline. The clinical syndrome is sepsis. The target patient population is adult patients in an academic medical center. The current empiric treatment for sepsis is C-2GC-AG.
Step 2 Susceptibility data Determine the local prevalence of resistance to the current empiric treatment (syndrome and population specific). Of all patients with suspected sepsis, 6.7% are diagnosed with Gram-negative bacteremia.* Gram-negative resistance for C-2GC-AG in blood culture isolates is 8.8%. In the study center. Methicillin resistant Staphylococcus aureus (MRSA) and penicillin resistant pneumococcal species are very rare in the Netherlands.
Step 3 Definition of risk factors Identify available predictors for resistance to the current empiric treatment. Independent risk factors of resistance to empiric sepsis therapy in the study population are prior antimicrobial use and prior isolates with a DRP.
Step 4 Targeted strategies Identify potential targeted treatment strategies. Option A: A carbapenem in patients with a DRP cultured the previous 6 months and C-2GC-AG in other patients.
Option B: a carbapenem in all patients with sepsis.
Step 5 Estimating benefit Estimate the proportion of patients that would be adequately treated if empiric sepsis therapy was changed. Option A: 95.2% of Gram-negative bloodstream infections would be treated adequately.
Option B: 99.8% of Gram-negative bloodstream infections would be treated adequately.
Step 6 Estimating costs Identify the number needed to treat (NNTC). Option A: NNTC is 42 patients.
Option B: NNTC is 173 patients.
Step 7 Selection of empiric treatment strategy Balance the cost and benefits of phase 5 and 6 to select the most appropriate strategy. A moral deliberation with stakeholders was performed to decide on the most appropriate antibiotic therapy for sepsis in the institution. Option A was selected.
Implementation and evaluation Evaluate the costs and benefits of the selected approach. After implementation of strategy A, adequacy rates, outcome, side-effects of antimicrobials and antimicrobial consumption were evaluated.
  1. Legend: NNTC = number of patients needed to treat with a carbapenem instead of cefuroxime/gentamicin to prevent one case of inappropriate empiric therapy, C-2GC-AG = cefuroxime combined with gentamicin, DRP = Drug resistant pathogen. * To estimate the overall blood culture positivity rate, the proportion of bacteremia was determined during two separate months, June and December 2014. During this period, all patients in whom blood cultures were obtained because of fever were included. In this pilot period, of all patients with suspected infection, 53/778 (6.7%) had positive blood cultures with a Gram-negative pathogen. All other data used in the example provided in column 3 are cohort data