Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients

Abstract

Objective To determine if time to initial antimicrobial is associated with progression of severe sepsis to septic shock. Design Retrospective cohort Setting 656 bed urban academic medical center Patients Emergency department patients ≥18 years of age with severe sepsis and/or septic shock and antimicrobial administration within 24 hours. Patients with shock on presentation were excluded. Interventions N/A. Measurements and Main Results We identified 3,929 severe sepsis patients, with overall mortality 12.8%. 984 (25.0%) patients progressed to septic shock. The median time to antimicrobial was 3.77 hours (IQR = 1.96 – 6.42) in those who progressed vs 2.76 hours (IQR = 1.60 – 4.82) in those who did not (p < 0.001). Multivariate logistic regression demonstrated that male sex (OR = 1.18; 95% CI, 1.01–1.36), Charlson Comorbidity Index (OR = 1.18; 95% CI, 1.11–1.27), number of infections (OR = 1.05; 95% CI, 1.02–1.08), and time to first antimicrobial (OR = 1.08; 95% CI, 1.06–1.10) were associated with progression. Each hour until initial antimicrobial administration was associated with a 8.0% increase in progression to septic shock. Additionally, time to broad spectrum antimicrobial was associated with progression (OR = 1.06; 95% CI, 1.05–1.08). Time to initial antimicrobial was also associated with in-hospital mortality (OR = 1.05; 95% CI, 1.03–1.07). Conclusions This study emphasizes the importance of early, broad spectrum antimicrobial administration in severe sepsis patients admitted through the emergency department, as longer time to initial antimicrobial administration is associated with increased progression of severe sepsis to septic shock and increased mortality.

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients

“…The chaotic administration of these therapies decreases the probability of benefit; the ICU could be considered the ideal place for protocols intended to more adequately organize therapies . Good practice requires prompt resuscitation, early antibiotic administration, protective mechanical ventilation, and early nutrition, preferably enteral. Evaluating nutrition risk and body composition can define nutrition therapy strategy.…”

“…These uncertainties should not deter nutrition therapy in critically ill patients, that is, devaluing it because of presumed inefficiency in reducing mortality could be an equivalent sin. In critical illness, there are few therapies that unequivocally reduce mortality, including early resuscitation and the use of broad‐spectrum antibiotics . Nutrition therapy should be seen more as a support for other therapies and an additional resource among a set of measures to decrease suffering and improve quality of life in survivors.…”

“…In critical illness, there are few therapies that unequivocally reduce mortality, including early resuscitation and the use of broad-spectrum antibiotics. 6,7,38 Nutrition therapy should be seen more as a support for other therapies and an additional resource among a set of measures to decrease suffering and improve quality of life in survivors. The impact of nutrition therapy on mortality is uncertain; some studies do not relate it to better outcomes, 14,[39][40][41][42][43] whereas others do.…”

Integrating molecular pathogenesis and clinical translation in sepsis-induced acute respiratory distress syndrome

“…Data from clinical studies support early antibiotics as a critical intervention for improving mortality from sepsis and development of end-organ dysfunction. Mortality from sepsis is 5 times higher when the initial antibiotic choice is inappropriate (48), and increased time to antibiotic administration is associated with progression to septic shock (49). Activation of the innate immune response following infection is regulated by various cellular pathways, including autophagy, a highly conserved pathway involved in clearing damaged proteins and organelles from cells.…”

Leveraging implicit expert knowledge for non-circular machine learning in sepsis prediction

“…Despite these efforts to better define sepsis, accurate diagnosis of sepsis remains a major clinical challenge. At the same time, delay of antibiotic treatment initiation in patients at stake to develop severe sepsis and septic shock by only few hours is associated with increased mortality (Ferrer et al, 2014;Whiles et al, 2017;Peltan et al, 2017). Considerable improvement of sepsis treatment thus lies in expediting its diagnosis, i.e., by designing reliable tools for early identification of patients developing sepsis.…”