Document Type


Subject Area(s)

Aged; Anti-Bacterial Agents (therapeutic use); Bacteremia (drug therapy, mortality); Cohort Studies; Female; Gram-Negative Bacterial Infections (blood, drug therapy, mortality); Humans; Inappropriate Prescribing (statistics & numerical data); Kaplan-Meier Estimate; Male; Middle Aged; Prognosis; Proportional Hazards Models; Retrospective Studies; South Carolina (epidemiology); Treatment Outcome


The bloodstream infection mortality risk score (BSIMRS) predicts the outcome of patients with Gram-negative bloodstream infections (BSI) with high discrimination. This retrospective cohort study examined the impact of inappropriate antimicrobial therapy on mortality in adult patients with Gram-negative BSI admitted to Palmetto Health Hospitals in Columbia, SC, USA, from 1 January 2011 to 31 December 2012 after stratification by predicted prognosis at initial presentation using BSIMRS. A multivariate Cox regression model was used to identify independent risk factors for 28-day mortality overall and within each predefined BSIMRS category (<5, 5 to 9, and ≥10). Relative risk reduction (RRR), absolute risk reduction (ARR), and number needed to treat (NNT) were calculated from a predictive logistic regression model of mortality. Overall, 390 unique patients with first episodes of Gram-negative BSI were identified. The median age was 66 years, and 229 (59%) were women. There was significant association between inappropriate antimicrobial therapy and mortality in patients with BSIMRS of 5 to 9 (adjusted hazard ratio [aHR], 3.55; 95% confidence intervals [CI], 1.22 to 8.31; P = 0.02) and BSIMRS of ≥10 (aHR, 4.99; 95% CI, 1.09 to 22.87; P = 0.04) but not in those with BSIMRS of <5 (aHR, 3.34; 95% CI, 0.17 to 22.77; P = 0.34). RRR, ARR, and NNT were 0.25, 0.02, and 63 for BSIMRS of <5; 0.56, 0.32, and 3 for BSIMRS of 5 to 9; and 0.39, 0.39, and 3 for BSIMRS of ≥10, respectively. There is a significant benefit from appropriate antimicrobial therapy in patients with Gram-negative BSI with guarded (BSIMRS of 5 to 9) and poor (BSIMRS of ≥10) predicted prognosis. Survival difference remains unclear among those with good predicted prognosis (BSIMRS of <5) at initial presentation.

Digital Object Identifier (DOI)


Copyright © American Society for Microbiology, Antimicrobial Agents and Chemotherapy., 2014.

APA Citation

Cain, S. E., Kohn, J., Bookstaver, P. B., Albrecht, H., & Al-Hasan, M. N. (2015). Stratification of the impact of inappropriate empirical antimicrobial therapy for gram-negative bloodstream infections by predicted prognosis. Antimicrobial Agents and Chemotherapy, 59(1), 245–250.