Delay of appropriate antibiotic treatment is associated with high mortality in patients with community-onset sepsis in a Swedish setting

Abstract

Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important. Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock. A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012-2013. The criterion Bearly appropriate antibiotic treatment^was defined as administration of the first dose of adequate antibiotics within 1 h, and the second dose given with less than 25% delay after the recommended dose interval. A high-risk patient was defined as a septic patient with either shock within 24 h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality. Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment. Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.

Low incidence of antibiotic-resistant bacteria in south-east Sweden: An epidemiologic study on 9268 cases of bloodstream infection

“…A major limitation is that individual patient data on severity of disease, site of infection and appropriate antibiotic treatment were not available in our database; we were thus unable to assess any association between antibiotic use and risk for antibiotic-resistant infection, or between specific empirical regimens and outcome. Nor could we determine if delay in appropriate antibiotic treatment was a risk factor for mortality as shown by Andersson et al [12] in a similar setting. Furthermore, other causes of mortality such as myocardial infarction, pulmonary embolus or respiratory failure were only registered as comorbidity and not evaluated as a primary cause of death.…”

“…In septic shock, mortality risk increases if antibiotic treatment is delayed [11,12]. Early appropriate empirical antibiotic treatment is therefore particularly important in septic shock, and must be initiated without delay before the results of blood cultures are available [13][14][15][16].…”

Sepsis Alerts in Emergency Departments: A Systematic Review of Accuracy and Quality Measure Impact

“…2 , 3 Delays in diagnosis of sepsis can lead to delay in treatment, 4 , 5 which can lead to increased morbidity and mortality. 6 Quality measures now track time to these treatments as process markers of successful care. 7 While studies have questioned some of the interventions, such as protocol-driven fluid resuscitation, 8 there is general agreement that early antibiotic administration reduces mortality from sepsis.…”

“…7 While studies have questioned some of the interventions, such as protocol-driven fluid resuscitation, 8 there is general agreement that early antibiotic administration reduces mortality from sepsis. 6 , 9 – 11 …”

Impact of Rapid Antimicrobial Susceptibility Testing in Gram-Negative Rod Bacteremia: a Quasi-experimental Study

“…The recognition that early initiation of appropriate antibiotic therapy is associated with improved outcomes in patients with serious infections, as well as the fact that early de-escalation reduces exposure to unnecessarily broad antibiotic therapy, has led to a desire to shorten the time required to complete antimicrobial susceptibility testing (16)(17)(18)(19)(20). This has generated growing interest and technology development designed to shorten the turnaround time of antimicrobial susceptibility testing for positive blood cultures as adoption of the rapid methods may facilitate achievement of important ASP targets.…”