Evaluation of clinical practice guidelines on outcome of infection in medical intensive care unit patients

All patients in a 20-bed medical intensive care unit (ICU) were prospectively followed for a 3-month period (phase I, 158 patients/1248 patient days) to collect baseline data before implementation of practice guidelines for infection management and were compared with all patients in the same unit during a 4-month period after guideline implementation (phase II, 180 patients/972 patient days). Total infections in phase I vs. phase II, respectively, were the following: lower respiratory tract infection (LRTI), 87 (55%) vs. 94 (52%); urinary tract infection (UTI), 35 (22%) vs. 41 (23%); and sepsis of undetermined etiology, 25 (16%) vs. 29 (16%). There were no significant differences in death (23% vs. 20%), cure or improvement of infection (54% vs. 57%), readmission to the unit (3.6% vs. 3.4%), hospital risk of death (mean, 29.7 vs. 30.3), predicted length of ICU stay (mean, 6.09 days vs. 5.93 days) in phases I and II, respectively. APACHE III score (mean, 64.6 vs. 59.4; P = not significant) and length of ICU stay were higher (mean, 7.9 days vs. 5.4 days; P < .001) in phase I vs. phase II. Rates for nosocomial infection in phase I vs. II (per 1000 patient medical ICU days) were the following: LRTI, 6.4 vs. 5.1; UTI, 4.0 vs. 4.1; soft tissue infection, 0.8 vs. 0; bacteremia, 0.8 vs. 2.0; and intravenous catheter infection, 0.8 vs. 1.0 (P = not significant). Costs of antibiotic acquisition were $548.0 per patient in phase I and $372.9 per patient in phase II (P < .001). Compliance with guideline recommendations was 84%. There were trends toward an increase in the susceptibility of Pseudomonas aeruginosa to ceftazidime (82% to 95% susceptible; P = .18) and imipenem (91% to 100% susceptible; P = .17) and of Enterobacterspecies (P = .04) to ceftazidime. In medical ICU patients in whom guidelines for management of infections were used, antibiotic costs and bacterial resistance both decreased without adversely affecting patient outcomes. This study has important implications for the management of infections in ICU patients.