Background
The prolonged β-lactam infusion strategy has emerged as the standard treatment for sepsis or septic shock despite its unknown efficacy. This study aimed to assess the efficacy of prolonged versus intermittent β-lactam antibiotics infusion on outcomes in sepsis or septic shock patients by conducting a systematic review and meta-analysis.
Methods
A thorough search was conducted on MEDLINE, the Cochrane Central Register of Controlled Trials, and the Igaku Chuo Zasshi databases. Randomized controlled trials (RCTs) comparing mortality between prolonged and intermittent infusion in adult patients with sepsis or septic shock were included. The primary outcome was hospital mortality. The secondary outcomes were the attainment of the target plasma concentration, clinical cure, adverse events, and occurrence of antibiotic-resistant bacteria. We performed a subgroup analysis stratified according to the year of publication before or after 2015 and a trial sequential analysis (TSA). The Der Simonian–Laird random-effects models were subsequently used to report the pooled risk ratios (RR) with confidence intervals (CI).
Results
We identified 2869 studies from the 3 databases, and 13 studies were included in the meta-analysis.
Fig 1. Flow diagram of the search strategy and study selection.
We identified 2869 studies from the 3 databases, and 13 studies were included in the meta-analysis. The forest plot of the primary outcome is shown in Fig. 2.
During hospitalization, 88 of the 420 patients (21.0%) died in the prolonged infusion group and 112 of 424 patients (26.4%) died in the intermittent infusion group. The pooled RR of hospital mortality did not decrease significantly (0.69 [95%CI 0.47–1.02]) in the prolonged infusion group. There were no significant differences in the adverse event and the occurrence of antibiotic resistant bacteria between the groups with pooled RR of 1.01 (95%CI 0.95–1.06) and 0.53 (95%CI 0.10–2.83), respectively (Fig. 3A, 3B).
Conclusion
The prolonged infusion of β-lactam antibiotics significantly improved upon attaining the target plasma concentration and clinical cure without increasing the adverse event or the occurrence of antibiotic-resistant bacteria. Prolonged infusion could not improve hospital mortality although an improvement was shown for studies published in or after 2015. Further studies are warranted as suggested by the TSA results.
Source: Kondo, Y., Ota, K., Imura, H. et al. Prolonged versus intermittent β-lactam antibiotics intravenous infusion strategy in sepsis or septic shock patients: a systematic review with meta-analysis and trial sequential analysis of randomized trials. j intensive care 8, 77 (2020). https://doi.org/10.1186/s40560-020-00490-z
