Italy versus the United Kingdom: differing styles for treating bacteremia in the critically ill patient, but who's right?

BACKGROUND: As no prospective, randomized, clinical trials (PRCTs) exist to inform decisions about antibiotic therapy for bacteraemia, ICUs have likely developed their own strategies. A multi-centre, multi-national questionnaire survey was used to assess variations in antibiotic strategy between ICUs in the United Kingdom (UK) and Italy.

METHODS: In January 2001, a detailed questionnaire regarding antibiotic policy was sent to international (e.g., European Society of Intensive Care Medicine, ESICM) and national societies (Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, GIVITI; Australia and New Zealand Intensive Care-Critical Trial Group, ANZIC-CTG; United Kingdom-Intensive Care Society, UK-ICS).

RESULTS: Out of the 254 participating ICUs, 81 were from Italy and 32 were from the UK. In the UK, ICUs preferred to use a shorter course of mono-therapy compared to Italian ICUs when treating, a) primary bacteremia [7 (5-7) vs 10 (7-14), P<0.001]; b) UTI [5 (4-7) vs 8 (7-10), P<0.001]; c) Staphylococcus aureus [7 (5-12) vs 10 (7-15), P<0.001]; and d) Gram-negative bacteraemia associated with lines [6 (5-7) vs 10 (7-15), P<0.001], pneumonia [7 (5-7) vs 14 (10-15), P<0.001] and peritonitis [7 (5-9) vs 15 (10-15), P<0.000]. These differences in treatment strategy were likely correlated with the median inter-quartile range (IQR) of weekly input from a microbiologist or infectious disease specialist, which was more frequent in the UK compared to Italy [5 (2-6) vs 0 (0-1), P<0.001].

CONCLUSION: Possible influences accounting for the variations found between Italy and the UK are: 1) differences in interactions with microbiologists or infectious disease specialists, 2) historical/educational dogma, and 3) antibiotic resistance patterns. Further studies are necessary to determine the optimal approach to treating bacteremia.