AAEM Clinical Practice
Does Early and Appropriate Antibiotic Administration Improve Mortality in Emergency Department Patients with Severe Sepsis or Septic Shock?

https://doi.org/10.1016/j.jemermed.2016.12.009Get rights and content

Abstract

Background

Severe sepsis and septic shock remain significant public health concerns. Appropriate emergency department management includes early recognition, hemodynamic resuscitation, source control, and prompt antibiotic administration. Current international guidelines strongly recommend administration of early and appropriate antibiotics for patients with severe sepsis and septic shock. Interestingly, a recent Cochrane Review found insufficient evidence to provide a similar recommendation on antibiotic administration. The goal of this literature search was to systematically review the available literature on early and appropriate antimicrobial therapy and provide emergency physicians an evidence-based approach to antibiotic therapy for septic patients.

Methods

Four PubMed searches were completed to identify abstracts of relevant interest. We limited studies to those completed in adult humans that were composed in English between 2005 and 2015. Included studies were randomized controlled trials, meta-analyses, prospective trials, and retrospective cohort studies. These studies were identified by a rigorous search methodology. No review articles, case series, or case reports were included. Predefined criteria were used to evaluate the quality and appropriateness of selected articles as part of a structured review.

Results

A total of 1552 abstracts were evaluated for inclusion. After the review of these studies, 14 were included for formal review. The authors then systematically evaluated each study, which formed the basis for this clinical statement.

Conclusions

Patients with severe sepsis and septic shock should receive early and appropriate antibiotics in the emergency department. Patients with septic shock who received appropriate antimicrobial therapy within 1 h of recognition had the greatest benefit in mortality.

Introduction

Severe sepsis and septic shock remain a significant public health concern, with > 750,000 cases per year in the United States (1). Although mortality has decreased in the past decade due to increased awareness and improved management, it still remains high, at approximately 20% in the most recent multicenter trials 2, 3, 4. In the emergency department (ED), standard care includes early recognition, aggressive hemodynamic resuscitation, source control, and prompt administration of antibiotics. In 2002, the Surviving Sepsis Campaign (SSC) was created by an international group of physicians, nurses, and pharmacists to promote optimal care for septic patients. The SSC released their latest guidelines in 2012, which included statements emphasizing that antibiotics be administered to patients with septic shock (1B) or severe sepsis (1C) within an hour of recognition (5). These recommendations were largely based on a landmark retrospective cohort study that showed for every hour delay in administering antibiotics to patients with septic shock, there was a 7.6% increase in mortality over the first 6 h (6). In 2010, a Cochrane Database Systemic Review evaluated the evidence of the mortality impact of antibiotic administration to patients with severe sepsis before admission to the intensive care unit (ICU) (7). The authors found no randomized or prospective trials to answer this question. They could not provide a strong recommendation for early antibiotic administration, although they did mention it is reasonable to do, based on available evidence. The objective of this American Academy of Emergency Medicine Clinical Practice statement is to summarize current evidence and provide guidance to emergency providers on the timing and selection of antimicrobial therapy in patients with severe sepsis and septic shock.

Section snippets

Methods

This was a structured literature review using a PubMed search for articles investigating the impact of antibiotic administration on outcomes of patients with severe sepsis and septic shock. Specifically, the impact of the time to administration of antibiotics and the appropriateness of selected antibiotics in patients with severe sepsis and septic shock was evaluated. Appropriateness of the selected antibiotic was defined a priori as an antimicrobial for which a pathogen showed in vitro

Results

A total of 1522 articles were identified by the four PubMed searches that met inclusion criteria. Of these, 14 were included in the final analysis: 8 retrospective cohort studies, 4 prospective cohort studies, 1 randomized controlled trial, and a single Cochrane Systemic Review (Table 4). Of the eight studies designed to assess the impact of timely antibiotic administration, seven showed a decrease in mortality, with the greatest benefit shown for patients in septic shock. Of the six articles

Recommendation

Early and appropriate antibiotic administration as described in the Methods section improves mortality in ED patients with severe sepsis and septic shock.

Level of recommendation: C.

Discussion

The ED management of patients with severe sepsis and septic shock is focused on the delivery of optimal and timely therapy. The goal of this clinical practice guideline is to provide emergency physicians with an evidence-based recommendation for the antimicrobial management of these patients. Defining the “appropriateness” of antibiotics can be challenging, as it is ultimately based on identifying a causative pathogen. In approximately one-third of cases, blood cultures identify a specific

Conclusions

Current evidence supports the use of appropriate antibiotics for patients with severe sepsis and septic shock in the ED. There is also strong evidence for the administration of appropriate antimicrobial therapy within the first hour of the recognition of patients with septic shock.

References (23)

  • A.L. Vilella et al.

    Timing and appropriateness of initial antibiotic therapy in newly presenting septic patients

    Am J Emerg Med

    (2014)
  • C.C. Lee et al.

    Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED

    Am J Emerg Med

    (2012)
  • D.C. Angus et al.

    Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care

    Crit Care Med

    (2001)
  • A randomized trial of protocol-based care for early septic shock

    N Engl J Med

    (2014)
  • ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock

    N Engl J Med

    (2014)
  • P.R. Mouncey et al.

    Trial of early, goal-directed resuscitation for septic shock

    N Engl J Med

    (2015)
  • R.P. Dellinger et al.

    Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012

    Crit Care Med

    (2013)
  • A. Kumar et al.

    Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock

    Crit Care Med

    (2006)
  • S. Siddiqui et al.

    Early versus late pre-intensive care unit admission broad spectrum antibiotics for severe sepsis in adults

    Cochrane Database Syst Rev

    (2010)
  • B. Parish et al.

    Effectiveness of early antibiotic administration in septic patients with cancer

    Acute Med

    (2012)
  • M. Jalili et al.

    Effect of door-to-antibiotic time on mortality of patients with sepsis in emergency department: a prospective cohort study

    Acta Med Iran

    (2013)
  • Cited by (73)

    • Application of metagenomic next-generation sequencing for suspected infected pancreatic necrosis

      2022, Pancreatology
      Citation Excerpt :

      Without accurate microbiological results, antibiotics often lead to more harm than benefit to the patients. Timely acquisition of microbiological diagnosis might change the strategy of interventions, reduce antibiotics usage, and thereby prevent bacteria resistance and even improve the outcomes of the patients [8,9]. Thus, it is imperative to uncover a simple and effective diagnostic method to obtain precise microbiological results in patients with suspected IPN.

    • Improved hospital mortality rates after the implementation of emergency department sepsis teams

      2022, American Journal of Emergency Medicine
      Citation Excerpt :

      Studies have shown that patients who present with severe sepsis and septic shock should receive early and appropriate antibiotics [11,12]. Patients with septic shock who received appropriate antibiotic therapy within one hour of recognition had the greatest benefit in mortality [12]. Since the ED is where many septic patients are seen initially, it is imperative to identify and treat sepsis early.

    View all citing articles on Scopus

    Clinical practice paper approved by the American Academy of Emergency Medicine Clinical Guidelines Committee.

    View full text