Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact. OBJECTIVE: This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery. METHODS: An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery. RESULTS: Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001). CONCLUSIONS: Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.

Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery. METHODS: All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis. RESULTS: A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01-1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14-1.58, p < 0.001), and open operative approach (RR 1.63, 95%CI 1.28-2.09, p < 0.001). Independent factors associated with hospital readmissions included rectal surgery (RR 1.89, 95%CI 1.34-2.77, p < 0.001), formation of a stoma (RR 1.34, 95%CI 1.04-1.74, p = 0.026), and reoperation during first admission (RR 4.60, 95%CI 3.50-6.05, p < 0.001). Length of stay of 5 days or less was not associated with ER visits or readmission (RR 0.99, 95%CI 0.72-1.35 and RR 0.91, 95%CI 0.71-1.18, respectively). CONCLUSION: Following colorectal surgery using an ERAS pathway, shortened length of stay is not associated with an increased return to the ER or hospital readmission. The majority of return visits to the hospital are ER visits not requiring readmission and the predominant reason for return are surgical site infections and wound complications.

Compliance with Urinary Catheter Removal Guidelines Leads to Improved Outcome in Enhanced Recovery After Surgery Patients.

OBJECTIVE: The objective of the study was to determine whether compliance with Enhanced Recovery after Surgery (ERAS) urinary catheter recommendations is associated with decreased urinary tract infections (UTI) and length of stay (LOS). METHODS: Patients having colorectal surgery at 15 academic hospitals were included. Patient and outcome data were collected prospectively. The guideline recommends that urinary catheters following colonic and rectal procedures should be removed at or before 24 and 72 h, respectively. RESULTS: Two thousand nine hundred and twenty-seven patients (1397 females and 1522 males; mean age 60.3 years) were enrolled. Small bowel or colonic procedures were performed in 1897 (64.9%) and rectal procedures in 1030 (35.2%) patients. Overall, 53.2% of patients had their catheter removed in compliance with the guidelines (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 0.8% of patients who were guideline compliant had a UTI compared to 4.1% non-compliant patients (RR 0.20, 95% CI 0.07-0.58; p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were non-compliant (RR 0.37, 95% CI 0.20-0.68; p = 0.001). Median LOS was decreased in compliant patients: 4 vs 5 days following colonic procedures (RR 0.73, 95% CI 0.66-0.82; p < 0.0001) and 5 vs 8 days following rectal procedures (RR 0.54, 95% CI 0.49-0.59; p < 0.001). CONCLUSION: Early removal of urinary catheters is associated with a decreased risk of UTI and LOS.

Optimizing Bariatric Surgery Multidisciplinary Follow-up: a Focus on Patient-Centered Care.

BACKGROUND: Failure to follow-up post-bariatric surgery has been associated with higher postoperative complications, lower percentage weight loss and poorer nutrition. OBJECTIVE: This study aimed to understand the patient follow-up experience in order to optimize follow-up care within a comprehensive bariatric surgery program. METHODS: Qualitative telephone interviews were conducted in patients who underwent surgery through a publically funded multidisciplinary bariatric surgery program in 2011, in Ontario, Canada. Inductive thematic analysis was used. RESULTS: Of the 46 patients interviewed, 76.1 % were female, mean age was 50, and 10 were lost to follow-up within 1 year postsurgery. Therapeutic continuity was the most important element of follow-up care identified by patients and was most frequently established with the dietician, as this team member was highly sought and accessible. Patients who attended regularly (1) appreciated the specialized care, (2) favoured ongoing monitoring and support, (3) were committed to the program and (4) felt their family doctor had insufficient experience/knowledge to manage their follow-up care. Of the 36 people who attended the clinic regularly, 8 were not planning to return after 2 years due to (1) perceived diminishing usefulness, (2) system issues, (3) confidence that their family physician could continue their care or (4) higher priority personal/health issues. Patients lost to follow-up stated similar barriers. CONCLUSION: Patients believe the follow-up post-bariatric surgery is essential in providing the support required to maintain their diet and health. More personalized care focusing on continuity and relationships catering to individual patient needs balanced with local healthcare resources may redefine and reduce attrition rates.

Preoperative predictors of adherence to multidisciplinary follow-up care postbariatric surgery.

BACKGROUND: Long-term multidisciplinary care after bariatric surgery is important for weight maintenance and management of co-morbidities. Despite this, the rate of attendance to follow-up appointments is universally low. OBJECTIVE: To identify patient factors that contribute to adherence to follow-up care after bariatric surgery. SETTING: Three university-affiliated hospitals in Canada METHODS: A cohort study of 388 patients who underwent bariatric surgery from January 2011 to December 2011 was performed. This program mandates multidisciplinary follow-up care at 3, 6, and 12 months, and annually thereafter. Patients' socioeconomic, psychosocial, and medical and psychiatric co-morbidities were recorded prospectively. Adherence to follow-up care was defined as having attended the majority of clinic visits (3 or 4 out of 4); all other patients were considered nonadherent. RESULTS: The mean age of patients was 45.0 years, 81.2% were female, and the majority underwent a gastric bypass (91.8%) versus a sleeve gastrectomy (8.2%); 62.1% of patients were adherent to follow-up appointments. Patients older than 25 years had a higher adherence rate than those who were younger (63.2% versus 37.5%, P = .040). Patients with full-time or part-time employment had a significantly higher adherence rate than those who were unemployed or retired (65.6% versus 50.0%, P = .017, odds ratio 1.9). Patients with obstructive sleep apnea (OSA) before surgery had higher follow-up adherence than those without OSA (62.2% versus 37.8%, P = .044). In multivariate analysis, employment remained an independent predictor of follow-up adherence (P = .017). CONCLUSION: Employment was the strongest predictor of attendance to follow-up clinic. Patients with OSA and older patients were also more likely to return consistently for scheduled follow-up.

Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. OBJECTIVE: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. METHODS: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. RESULTS: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. CONCLUSIONS: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

A multifaceted knowledge translation strategy can increase compliance with guideline recommendations for mechanical bowel preparation.

The successful transfer of evidence into clinical practice is a slow and haphazard process. We report the outcome of a 5-year knowledge translation (KT) strategy to increase adherence with a clinical practice guideline (CPG) for mechanical bowel preparation (MBP) for elective colorectal surgery patients. A locally tailored CPG recommending MBP practices was developed. Data on MBP practices were collected at six University of Toronto hospitals before CPG implementation as well as after two separate KT strategies. KT strategy #1 included development of the CPG, education by opinion leaders, reminder cards, and presentations of data. KT strategy #2 included selection of hospital champions, development of communities of practice, education, reminder cards, electronic updates, pre-printed standardized orders, and audit and feedback. A total of 744 patients (400 males, 344 females, mean age 57.0) were included. Compliance increased from 58.6 to 70.4% after KT strategy #1 and to 81.1% after KT strategy #2 (p < 0.001). Using a tailored KT strategy, increased compliance was observed with CPG recommendations over time suggesting that a longitudinal KT strategy is required to increase and sustain compliance with recommendations. Furthermore, different strategies may be required at different times (i.e., educational sessions initially and reminders and standardized orders to maintain adherence).

A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program.

OBJECTIVE: Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients. BACKGROUND: ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow. METHODS: Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews. RESULTS: Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential. CONCLUSIONS: Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

Understanding surgical residents' postoperative practices and barriers and enablers to the implementation of an Enhanced Recovery After Surgery (ERAS) Guideline.

INTRODUCTION: An Enhanced Recovery after Surgery (ERAS) Clinical Practice Guideline (CPG) was developed at the University of Toronto. Before implementation, general surgery residents were surveyed to assess their current stated practices and their perceived barriers and enablers to early discharge. METHODS: The survey, which consisted of 33 questions related to the postoperative management of patients undergoing laparoscopic colectomy (LAC), open colectomy (OC) and open low anterior resection (LAR), was distributed to all residents. Chi-square and Fisher exact tests were used to test differences. Open-ended questions were analyzed using content analysis. RESULTS: Of 77 residents surveyed, 58 (75%) responded. Residents stated that a fluid diet would be ordered on POD#0 and regular diet on POD#1 by 67.9% and 49.1%, respectively, following LAC, and 50.0% and 25.9%, respectively, following OC. On POD#1, 89.3% expected patients to ambulate following LAC compared with 67.9% following OC. Residents indicated that urinary catheters would be removed on POD#1 by 87% following LAC and by 81.3% following OC, and by POD#3 by 89.1% following LAR. However, in patients with an epidural, approximately 50% of residents stated that they would wait until it was removed. Overall, 76.4% of residents agreed that an ERAS CPG should be adopted. Residents cited setting expectations, encouragement of early ambulation and feeding, and good pain control as enablers to early discharge. However, patient and family expectations, surgeon preferences, and beliefs of the health care team were mentioned as barriers to early discharge. CONCLUSION: Residents have a reasonable approach to the management of patients who underwent LAC, but there are gaps that exist in their management, especially following OC and LAR. Although most residents agreed with the implementation of an ERAS CPG, barriers exist, and strategies aimed at ensuring adherence with the recommendations are required.

Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay.

OBJECTIVE: The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery, and shorten hospital stay. This study was designed to determine which ERAS strategies contribute to overall shortened length of hospital stay in patients undergoing elective colorectal surgery in hospitals. METHODS: A retrospective cohort study of 336 consecutive patients at seven hospitals was performed. Demographic and data on 18 ERAS components identified from a systematic review of the literature were collected. A multiregression analysis was performed to assess for factors independently associated with a total length of hospital stay of 5 days or less. RESULTS: Fifty-five percent were male (mean age, 62 years), 57.5% had an ASA III or IV, 76.9% had cancer, and 28.6% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On bivariate analysis, strategies associated with a stay ≤ 5 days were preoperative counseling, avoidance of oral bowel preparation, use of a laparoscopic approach, use of a transverse incision, introduction of clear fluids on day of surgery, and early discontinuation of the Foley catheter (all P < 0.05). On multivariate analysis, factors that remained significantly associated with a stay ≤ 5 days included use of a laparoscopic approach (odds ratio (OR), 1.24; 95% confidence interval (CI), 1.12-1.38), preoperative counseling (OR, 1.26; 95% CI, 1.15-1.38), intraoperative fluid restriction (OR, 1.26; 95% CI, 1.15-1.37), clear fluids on day of surgery (OR, 1.09; 95% CI, 1.00-1.2), and Foley urinal catheter discontinued within 24 h of colon surgery and 72 h of rectal surgery (OR, 1.13; 95% CI, 1.01-1.27). CONCLUSIONS: In hospitals with variable uptake of ERAS strategies, preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, and early discontinuation of the Foley catheter are all independently associated with shortened length of stay.

CAGS and ACS Evidence Based Reviews in Surgery. 34: effects of ß-blockers in patients undergoing noncardiac surgery.

QUESTION: Do ß-blockers have an effect on the 30-day risk of major cardiovascular events in patients with or at risk of atherosclerotic disease undergoing noncardiac surgery? DESIGN: Randomized controlled trial. SETTING: Multicentre trial in 190 hospitals in 23 countries. PATIENTS: In total, 8351 patients with or at risk of atherosclerotic disease undergoing noncardiac surgery. INTERVENTION: Patients were randomly assigned by a computerized 24-hour phone service to receive extended-release metoprolol succinate 200 mg (n = 4174) or placebo (n = 4177). Treatment was started 2-4 hours before surgery and continued for 30 days. MAIN OUTCOME: Cardiovascular death, nonfatal myocardial infarction (MI) and nonfatal cardiac arrest. RESULTS: Of those randomized, 8331 (99.8%) patients completed the 30-day follow-up. Fewer patients in the metoprolol group than in the placebo group had an MI (176 [4.2%] v. 239 [5.7%] patients; hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.60-0.089, p = 0.0017). However, there were more deaths in the metoprolol group than in the placebo group (129 [3.1%] v. 97 [2.3%] patients; HR 1.33, 95% CI 1.03-1.74, p = 0.0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1.0%] v. 19 [0.5%] patients; HR 2.17, 95% CI 1.26-3.74, p = 0.0053). CONCLUSION: A perioperative ß-blocker regimen results in fewer MIs but is associated with an increased risk of stroke and perioperative death in patients with or at risk for atherosclerotic disease undergoing noncardiac surgery. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol use.

Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials.

BACKGROUND: Enhanced recovery after surgery programs have been introduced with aims of improving patient care, reducing complication rates, and shortening hospital stay following colorectal surgery. The aim of this meta-analysis was to determine whether enhanced recovery after surgery programs, when compared to traditional perioperative care, are associated with reduced primary hospital length of stay in adult patients undergoing elective colorectal surgery. METHODS: MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials, and the reference lists were searched for relevant articles. Only randomized controlled trials comparing an enhanced recovery program with traditional postoperative care were included. RESULTS: Three of four included studies showed significantly shorter primary lengths of stay for patients enrolled in enhanced recovery programs. There was no significant difference in postoperative mortality when the two groups were compared [relative risk (RR) = 0.53; 95% CI = 0.12-2.38; test for heterogeneity, p = 0.40 and I (2) = 0], and patients in enhanced recovery programs were less likely to develop postoperative complications (RR = 0.61, 95% CI = 0.42-0.88; test for heterogeneity, p = 0.95 and I (2) = 0). AUTHORS' CONCLUSIONS: There is some evidence to suggest that enhanced recovery after surgery programs are better than traditional perioperative care, but evidence from a larger, better quality randomized controlled trial is necessary.

Empiric antibiotic therapy for suspected ventilator-associated pneumonia: a systematic review and meta-analysis of randomized trials.

OBJECTIVE: To compare specific antibiotic regimens, and monotherapy vs. combination therapy, for the empirical treatment of ventilator-associated pneumonia (VAP). DESIGN: Meta-analysis. DATA SOURCE: Medline, Embase, Cochrane register of controlled trials, study authors, and review articles. STUDY SELECTION: We included randomized controlled trials that evaluated empirical parenteral antibiotic regimens for adult patients with clinically suspected VAP. DATA SELECTION: Two independent review groups searched the literature, extracted data, and evaluated trial quality. The primary outcome was all-cause mortality; secondary outcomes included treatment failure. Relative risks were pooled using a random effects model. RESULTS: We identified 41 trials randomizing 7,015 patients and comparing 29 unique regimens. Methodological quality was low, reflecting low rates of complete follow-up (43.9%), use of a double-blinded interventional strategy (14.6%), and randomization concealment (48.6%). Overall mortality was 20.3%; treatment failure occurred in 37.4% of patients who could be evaluated microbiologically. No mortality differences were observed between any of the regimens compared. Only one of three pooled comparisons yielded a significant difference for treatment failure: The combination of ceftazidime/aminoglycoside was inferior to meropenem (two trials, relative risk 0.70, 95% confidence interval 0.53-0.93). Rates of mortality and treatment failure for monotherapy compared with combination therapy were similar (11 trials, relative risk for mortality of monotherapy 0.94, confidence interval 0.76-1.16; and relative risk of treatment failure for monotherapy 0.88, confidence interval 0.72-1.07). CONCLUSIONS: Monotherapy is not inferior to combination therapy in the empirical treatment of VAP. Available data neither identify a superior empirical regimen nor conclusively conclude that available regimens result in equivalent outcomes. Larger and more rigorous trials evaluating the choice of, and even need for, empirical therapy for VAP are needed.

Empiric antimicrobial therapy in critical illness: results of a surgical infection society survey.

BACKGROUND: Antibiotics are prescribed commonly in the intensive care unit (ICU). Often, therapy is initiated empirically; practice patterns are not well characterized. We documented approaches to empiric antibiotic therapy among members of the Surgical Infection Society (SIS). METHODS: We sent a scenario-based questionnaire to all SIS members. The hypothetical cases addressed empiric broad-spectrum therapy for a patient with pyrexia and leukocytosis and the use of vancomycin for central venous catheter infection. RESULTS: The 113 respondents were primarily surgeons (96%) with a university-based practice (92%). Most attended in the ICU (72%), and they had practiced for 14 +/- 8 years. Whereas 63% of the respondents identified overuse of antibiotics as a problem in their ICU, only 19% said inadequate treatment of infection was a concern. For a febrile patient with negative cultures who was receiving antibiotics, estimates of the likelihood of infection increased across the three scenarios as the degree of organ failure increased (p < 0.0001; chi-square test). Deteriorating organ function was associated with a decision to broaden empiric therapy (58% vs. 33%; p < 0.0001) and to initiate anti-fungal therapy (27% vs. 9%; p < 0.0001) rather than to stop antibiotics and re-culture (15% vs. 51%; p < 0.0001). There was considerable variability in management strategy across the scenarios: Even in the face of organ dysfunction, 58% of physicians would add or change empiric therapy, whereas 30% would not. For each scenario, 23 to 25 antibiotic regimens were designated as optimal therapy. Only 45% of the respondents would initiate empiric vancomycin for suspected central line infection. Variability in approach was not explained by critical care practice, academic position, or country. CONCLUSIONS: Clinical deterioration is a strong determinant of a decision to initiate or broaden empiric antibiotic therapy during critical illness. The substantial variability in approach suggests a state of clinical equipoise that calls for more rigorous evaluation through a randomized controlled trial.

Antibiotic management of suspected nosocomial ICU-acquired infection: does prolonged empiric therapy improve outcome?

OBJECTIVE: To characterize empiric antibiotic use in patients with suspected nosocomial ICU-acquired infections (NI), and determine the impact of prolonged therapy in the absence of infection. DESIGN AND SETTING: Multicenter prospective cohort, with eight medical-surgical ICUs in North America and Europe. PATIENTS: 195 patients with suspected NI. METHODS: The diagnosis of NI was adjudicated by a blinded Clinical Evaluation Committee using retrospective review of clinical, radiological, and culture data. RESULTS: Empiric antibiotics were prescribed for 143 of 195 (73.3%) patients with suspected NI; only 39 of 195 (20.0%) were adjudicated as being infected. Infection rates were similar in patients who did (26 of 143, 18.2%), or did not (13 of 52, 25.0%) receive empiric therapy (p = 0.3). Empiric antibiotics were continued for more than 4 days in 56 of 95 (59.0%) patients without adjudicated NI. Factors associated with continued empiric therapy were increased age (p = 0.02), ongoing SIRS (p = 0.03), and hospital (p = 0.004). Patients without NI who received empiric antibiotics for longer than 4 days had increased 28-day mortality (18 of 56, 32.1%), compared with those whose antibiotics were discontinued (3 of 39, 7.7%; OR = 5.7, 95% CI 1.5-20.9, p = 0.005). When the influence of age, admission diagnosis, vasopressor use, and multiple organ dysfunction was controlled by multivariable analysis, prolonged empiric therapy was not independently associated with mortality (OR = 3.8, 95% CI 0.9-15.5, p = 0.07). CONCLUSIONS: Empiric antibiotics were initiated four times more often than NI was confirmed, and frequently continued in the absence of infection. We found no evidence that prolonged use of empiric antibiotics improved outcome for ICU patients, but rather a suggestion that the practice may be harmful.