Accuracy of antibiotics use in patients with severe sepsis or septic shock in the Emergency Department
Keywords:sepsis, antibiotics, Emergency Department
Objectives The purpose of this study was to evaluate the efficacy of antibiotics used by emergency physicians for treatment of pathogenic bacteria in severe sepsis and septic shock patients and to investigate the impact of antibiotic use on mortality and length of hospital stay of patients.
Methods A retrospective review of data of patients who had been diagnosed either severe sepsis and or septic shock in the Emergency Department (ED) of Maharaj Nakorn Chiang Mai Hospital from June 2011 through May 2012. Data on emergency physician decisions regarding use of antibiotics and the results of blood culture and sensitivity to antibiotic were recorded.
Results One-hundred and thirty-six patients were eligible for this study, of whom 33 (24.26%) were severe sepsis cases and 103 (75.74%) were septic shock cases. Antibiotics coverage was 80.9% for the severe sepsis patients and 82.9% for the septic shock patients. In the severe sepsis cases, the mortality rate among patients receiving antibiotics was lower than those who did not receive coverage antibiotics (20% vs. 25%, respectively, p = 0.048). In the patients with septic shock, mortality in the group receiving antibiotics was less than in the group that did not receive antibiotics (28.3% vs. 30.0%, respectively, p = 0.012). In both groups, there was no difference in the duration of hospital stay between patients who received proper antibiotic coverage and those who did not 14.5 days, [interquartile range (IQR) 3-19 days] vs. 14.3 days [IQR 4-26 days], respectively (p = 0.974) for the severe sepsis group and 18.2 days [IQR 5-28 days] vs. 11.1 days [IQR 4-17 days] (p = 0.287) for the septic shock patients.
Conclusions Four out of five patients with severe sepsis or septic shock who arrived in the emergency department received the appropriate antibiotic selected by the emergency physicians. Administration of appropriate antibiotics can potentially reduce mortality.
2. Ispahani P, Pearson NJ, Greenwood D. An analysis of community and hospital-acquired bacteraemia in a large teaching hospital in the United Kingdom. Q J Med. 1987;63:427-40.
3. Leibovici L, Greenshtain S, Cohen O, Mor F, Wysenbeek AJ. Bacteremia in febrile patients. A clinical model for diagnosis. Arch Intern Med. 1991;151:1801-6.
4. Bates DW, Pruess KE, Lee TH. How bad are bacteremia and sepsis? Outcomes in a cohort with suspected bacteremia. Arch Intern Med. 1995;155:593-8.
5. Haug JB, Harthug S, Kalager T, Digranes A, Solberg CO. Bloodstream infections at a Norwegian university hospital, 1974-1979 and 1988-1989: changing etiology, clinical features, and outcome. Clin Infect Dis Off Publ Infect Dis Soc Am. 1994;19:246-56.
6. Strehlow MC, Emond SD, Shapiro NI, Pelletier AJ, Camargo CA. National study of emergency department visits for sepsis, 1992 to 2001. Ann Emerg Med. 2006;48:326-31.
7. Leibovici L, Shraga I, Drucker M, Konigsberger H, Samra Z, Pitlik SD. The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection. J Intern Med. 1998;244:379-86.
8. Harbarth S, Garbino J, Pugin J, Romand JA, Lew D, Pittet D. Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med. 2003;115:529-35.
9. Salomão R, Castelo Filho A, Pignatari AC, Wey SB. Nosocomial and community acquired bacteremia: variables associated with outcomes. Rev Paul Med. 1993;111:456-61.
10. Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000;118:146-55.
11. Leone M, Bourgoin A, Cambon S, Dubuc M, Albanèse J, Martin C. Empirical antimicrobial therapy of septic shock patients: adequacy and impact on the outcome. Crit Care Med. 2003;31:462-7.
12. Lee CC, Lee CH, Chuang MC, Hong MY, Hsu HC, Ko WC. Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED. Am J Emerg Med. 2012;30:1447-56.
13. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580-637.
14. Calandra T, Cohen J, International Sepsis Forum Definition of Infection in the ICU Consensus Conference. The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med. 2005;33:1538-48.
15. Francis M, Rich T, Williamson T, Peterson D. Effect of an emergency department sepsis protocol on time to antibiotics in severe sepsis. CJEM. 2010;12:303-10.
16. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia: link between quality of care and resource utilization. Arch Intern Med. 2002;162:682-8.
17. Capp R, Chang Y, Brown DFM. Effective antibiotic treatment prescribed by emergency physicians in patients admitted to the intensive care unit with severe sepsis or septic shock: where is the gap? J Emerg Med. 2011;41:573-80.