193 - Adding Insalt to Injury: Evaluating the Consequences of Sepsis Protocols on Patients with Heart Failure

Background: Inpatients with acute decompensated heart failure (ADHF) frequently meet sepsis criteria defined by the systemic inflammatory response syndrome (SIRS). To meet CMS guidelines, they receive a fluid bolus and broad-spectrum antibiotics, like piperacillin/tazobactam (pip/tazo), within 3 hours of presentation. A daily regimen of pip/tazo can contain as much as 1040 mg, or half the recommended dietary intake, of sodium. The objective of this investigation was to evaluate volume overloading and clinical consequences of sepsis protocols in patients with ADHF.

Methods: We reviewed inpatients ≥18 years old with ADHF per ICD-10 codes and an IV loop diuretic order who were initiated on a sepsis bundle, identified by IV fluid bolus and IV antibiotic orders. Patients who received ≥16 g of pip/tazo consecutively were compared to those who received other antibiotics. Outcomes included change in fluid homeostasis defined by increase in diuretic dose or frequency, or a weight increase ≥1 kg within a calendar day after receiving antibiotics; discharge disposition, length of stay (LOS), and 30-day readmission.

Results: We identified 95 patients admitted from 2/1/19 – 8/1/19. Thirty-four received pip/tazo, 61 received other antibiotics. Average age was 75, and 70% of patients had an infectious diseases diagnosis on discharge.  Fluid homeostasis was poorer in the pip/tazo group compared to the other antibiotics group, demonstrated by weight increase ≥ 1kg (42% vs. 38%) and/or increase in diuretic intensity (65% vs. 51%). 30-day readmission rate was 2.9% in the pip/tazo group and 4.9% in the other antibiotics group. Median LOS was 11.5 vs. 7 days for the pip/tazo group and other antibiotics group, respectively. Rate of mortality was 32.6% during this encounter.

Conclusion: Early initiation of fluids and antibiotics may be detrimental in those without an infectious syndrome based on disrupted fluid homeostasis. Given lower sodium burden associated with other antibiotic selections, this has implications for antimicrobial stewardship.