AAEM Clinical PracticeDoes Early and Appropriate Antibiotic Administration Improve Mortality in Emergency Department Patients with Severe Sepsis or Septic Shock?
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.
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Clinical practice paper approved by the American Academy of Emergency Medicine Clinical Guidelines Committee.