• Romy Schuttevaer, Anniek Brink, Jelmer Alsma, Willian van Dijk, Damian C Melles, de Steenwinkel Jurriaan E M JEM Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, Netherland, Hester F Lingsma, Annelies Verbon, and Schuit Stephanie C E SCE Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, Netherlands..
• Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, 3015 GD Rotterdam, Netherlands.
• Eur. J. Intern. Med. 2020 Aug 1; 78: 69-75.

ObjectiveNon-adherence to antimicrobial guidelines in patients with bloodstream infection can result in undertreatment, overtreatment, or equivalent treatment, and could lead to suboptimal care. Our aim was to examine the association between non-adherence and appropriate coverage as well as to assess the impact of non-adherence on 30-day mortality.MethodsWe conducted a retrospective cohort study between 2012 and 2017 at a tertiary university hospital. Adult patients attending the emergency department with a bloodstream infection were included. Adherence was defined as guideline-recommended antibiotic therapy. Non-adherence was either undertreatment (too narrow-spectrum), overtreatment (too broad-spectrum), or equivalent treatment. Outcomes were appropriate coverage (i.e. antibiotic therapy that matches in vitro susceptibility of the isolated bacteria) and 30-day mortality.ResultsWe included 909 patients of whom 395 (43.5%) were treated adherently, 355 (39.1%) were undertreated, 87 (9.6%) were overtreated, and 72 (7.9%) received an equivalent treatment. Overtreated patients were more severely ill, whilst undertreated patients had more favorable patient characteristics. Overtreatment did not result in higher appropriate coverage, whereas undertreatment was associated with lower coverage (OR[95%CI]: 0.18 [0.12; 0.26]). Overtreatment and undertreatment were not associated with 30-day mortality.ConclusionsGuideline adherence likely depends on disease severity, because overtreatment was more often observed in patients with high disease severity and undertreatment in less severely ill patients. Undertreatment was associated lower appropriate coverage but not with higher mortality. However, this can be the result of residual confounding . Overtreatment did not result in higher appropriate antibiotic coverage nor a survival benefit . Therefore, overtreatment seems not justifiable.Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.

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