Impact of early antibiotics on severe sepsis – are we doing a good job?

Introduction

Despite improvements in technology and healthcare services, mortality rates from severe sepsis have remained unchanged over the past few decades. Exciting new data are emerging about the benefits of early, aggressive management in the Emergency Room (ER). We carried out this study to study the patterns of antibiotic administration in our ER and their effects on the length of hospitalization and survival.

Methods

This was a prospective, observational cohort study that reviewed all adult patients presenting with systemic inflammatory response syndrome (SIRS) to the ER of the Aga Khan University Hospital, which is a 554-bed primary care/tertiary care referral facility, over a period from February to June 2006. SIRS was defined according to the criteria proscribed by the Society of Critical Care Medicine. A research officer stationed in the ER identified patients. Exclusion criteria were age < 18 years, patients transferred from other hospitals or chronic care facilities. Demographic and study-specific data were collected. The patient was followed until subsequent death or discharge. The primary outcome variable was survival to hospital discharge and the secondary outcome was length of hospitalization. An independent t-test analysis was carried out for the primary independent variable (timing of administration of antibiotics) and primary outcome (mortality) for significant differences between the groups. A two-sided P value < 0.05 was considered as statistical significance. Logistic regression modeling was used to examine survival as a function of timing of antibiotic administration.

Results

Patients enrolled in the study numbered 111. At presentation 36 patients (32.4%) had 1/4 criteria for SIRS, 67 (60.4%) had 2/4 criteria and only eight (7.2%) patients had 3/4 criteria. Sixteen patients (14.4%) were in shock. Sepsis was confirmed by cultures in 96 (86.5%) patients. One hundred (90.1%) patients received intravenous antibiotics in the ER; the average time from triage to actual administration was 2.8 (± 1.86) hours. The timing of administration of antibiotics was statistically significant in determining survival. Patients with sepsis and receiving antibiotics in <1 hour had a mean survival of 99% and a length of hospitalization of 3 days as compared with those receiving antibiotics in 1–4 hours (84.5% survival, LOS 5.25 days) and patients who received antibiotics in >4 hours (76% survival, LOS 7 days, P < 0.003). Using a Cox regression model, we were able to demonstrate that survival dropped acutely with an hourly delay in antibiotic administration. Overall mortality with sepsis was 34.2%.

Conclusion

Administration of appropriate antibiotics within 4 hours of arrival in the ER has a significantly favorable impact on survival in patients with sepsis.

Figure 1

(abstract P83)