Open Access Highly Accessed Open Badges Research article

Development of quality indicators for antimicrobial treatment in adults with sepsis

Caroline MA van den Bosch1*, Marlies EJL Hulscher2, Stephanie Natsch3, Inge C Gyssens456, Jan M Prins1, Suzanne E Geerlings1 and Dutch Sepsis QI expert panel

Author Affiliations

1 Department of Internal Medicine, division of Infectious Diseases, Center for Infection and Immunity Amsterdam (CINIMA) Academic Medical Center, Meibergdreef 9, 1105, AZ Amsterdam Zuidoost, The Netherlands

2 Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands

3 Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands

4 Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands

5 Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands

6 Hasselt University, Hasselt, Belgium

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BMC Infectious Diseases 2014, 14:345  doi:10.1186/1471-2334-14-345

Published: 20 June 2014



Outcomes in patients with sepsis are better if initial empirical antimicrobial use is appropriate. Several studies have shown that adherence to guidelines dictating appropriate antimicrobial use positively influences clinical outcome, shortens length of hospital stay and contributes to the containment of antibiotic resistance.

Quality indicators (QIs) can be systematically developed from these guidelines to define and measure appropriate antimicrobial use. We describe the development of a concise set of QIs to assess the appropriateness of antimicrobial use in adult patients with sepsis on a general medical ward or Intensive Care Unit (ICU).


A RAND-modified, five step Delphi procedure was used. A multidisciplinary panel of 14 experts appraised and prioritized 40 key recommendations from within the Dutch national guideline on antimicrobial use for adult hospitalized patients with sepsis ( webcite). A procedure to select QIs relevant to clinical outcome, antimicrobial resistance and costs was performed using two rounds of questionnaires with a face-to-face consensus meeting between the rounds over a period of three months.


The procedure resulted in the selection of a final set of five QIs, namely: obtain cultures; prescribe empirical antimicrobial therapy according to the national guideline; start intravenous drug therapy; start antimicrobial treatment within one hour; and streamline antimicrobial therapy.


This systematic, stepwise method, which combined evidence and expert opinion, led to a concise and therefore feasible set of QIs for optimal antimicrobial use in hospitalized adult patients with sepsis. The next step will entail subjecting these quality indicators to an applicability test for their clinimetric properties and ultimately, using these QIs in quality-improvement projects. This information is crucial for antimicrobial stewardship teams to help set priorities and to focus improvement.

Sepsis; Antimicrobial treatment; Quality indicator; Quality improvement; Appropriate antimicrobial use; Appropriate antibiotic use