Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis

A newly developed, easy-to-use prehospital drug-derived score compared with three conventional scores: A prospective multicenter study

INTRODUCTION

The use of medications by emergency medical services (EMS) is increasing. Conventional scores are time-consuming and therefore difficult to use in an emergency setting. For early decision-making, an easy-to-use score based on the medications administered by the EMS may have prognostic value. The primary objective of this study was to develop the prehospital drug-derived score (PDDS) for 2-day mortality.

METHODS

A prospective, multicenter, ambulance-based cohort study was conducted in adults with undifferentiated acute diseases treated by EMS and transferred to the emergency department. Demographic data, prehospital diagnosis data, prehospital medication and variables for the calculation of the National Early Warning Score 2 (NEWS2), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) were collected. The PDDS was developed and validated, establishing three levels of risk of 2-day mortality. The predictive capability of each score was determined by the area under the curve of the receiver operating characteristic curve (AUROC) and compared using the Delong's test (p-value).

RESULTS

A total of 6401 patients were included. The PDDS included age and the use of norepinephrine, analgesics, neuromuscular blocking agents, diuretics, antihypertensive agents, tranexamic acid, and bicarbonate. The AUROC of PDDS was .86 (95% CI: .816-.903) versus NEWS2 .866 (95% CI: .822-.911), p = .828; versus REMS .885 (95% CI: .845-.924), p = .311; versus RAPS .886 (95% CI: .846-.926), p = .335, respectively.

CONCLUSION

The newly developed easy-to-use prehospital drug-derived PDDS score has an excellent predictive value of early mortality. The PDDS score was comparable to the conventional risk scores and therefore might serve as an alternative score in the prehospital emergency setting.

Septic shock in the prehospital setting: a scoping review

Septic shock (SS) is a potential life-threatening condition in which an early identification and immediate therapy stand out as the main cornerstones to improve survival chance; in this context, emergency medical services (EMS) become key to reduce the time between diagnosis and management in the ICU or emergency department. However, guidelines for the prehospital management of SS patients remains unclear, and literature around this topic is scant. Our scoping review was conducted following the PICO framework and a search strategy related to septic shock management and diagnosis in prehospital settings was executed in PubMed, Scopus and Virtual Health Library; articles in English and Spanish from 2015, onwards, were screened by the authors and selected by mutual consensus. Our aim is to analyze the prehospital management strategies of SS reported in the literature, and to showcase and summarize the screening tools, demographic factors, clinical manifestations and prognostic factors of SS in the prehospital setting.

Prehospital blood gas analyses in acute patients treated by a ground-based physician-manned emergency unit: a cohort study

BACKGROUND

The prehospital patients treated by ambulances and mobile emergency care units (MECU) are potentially critically ill or injured. Knowing the risks of serious outcomes in these patients is important for guiding their treatment. Some settings allow for prehospital arterial blood gas analyses. This study aimed to assess the outcomes of prehospital patients in relation to their prehospitally measured lactate, pH, and CO2 levels. The primary outcome was 7-day mortality.

METHODS

This register-based cohort study included patients with one or more prehospital blood gas analyses during their prehospital treatment by a physician-manned MECU, from January 2015 to December 2018. The blood samples were analyzed on an ABL90 Flex analyzer. Absolute values with percentages and odds ratios (OR) with 95% confidence intervals (CI) were calculated for the primary and secondary outcomes within prespecified subgroups.

RESULTS

The study included 745 patients, with an overall 7-day mortality rate of 20.0%.

LACTATE LEVEL

The 7-day mortality rates were 11.5% in patients with normal lactate levels (< 2.0 mmol/L), 14.4% with intermediate lactate levels (2.0-3.9 mmol/L), and 33.0% with high lactate levels (≥ 4.0 mmol/L). This corresponded to an OR of 1.30 (95% CI: 0.75-2.24) in the intermediate lactate group (2.0-3.9 mmol/L) and an OR of 3.77 (95% CI: 2.44-5.85) in the high lactate group (≥ 4.0 mmol/L), compared to the reference group with normal lactate.

PH LEVEL

The ORs of 7-day mortality rates were 4.82 (95% CI: 3.00-7.75) in patients with blood pH of < 7.35 and 1.33 (95% CI: 0.65-2.72) in patients with blood pH > 7.45, compared to the reference group with normal pH (7.35-7.45). CO2 LEVEL : The ORs of 7-day mortality rates were 2.54 (95% CI: 1.45-4.46) in patients with blood CO2 of < 4.3 kPa and 2.62 (95% CI: 1.70-4.03) in patients with blood CO2 > 6.0 kPa, compared to the reference group with normal CO2 (4.3-6.0 kPa).

CONCLUSIONS

This study found a strong correlation between increasing 7-day mortality rates and high blood lactate levels, low levels of pH, and abnormal CO2 blood levels, in prehospital patients undergoing prehospital blood analysis.

Does Prehospital Suspicion of Sepsis Shorten Time to Administration of Antibiotics in the Emergency Department? A Retrospective Study in One University Hospital

Early treatment is the mainstay of sepsis therapy. We suspected that early recognition of sepsis by prehospital healthcare providers may shorten the time for antibiotic administration in the emergency department. We retrospectively evaluated all patients above 18 years of age who were diagnosed with sepsis or severe infection in our emergency department between 2018 and 2020. We recorded the suspected diagnosis at the time of presentation, the type of referring healthcare provider, and the time until initiation of antibiotic treatment. Differences between groups were calculated using the Kruskal-Wallis rank sum test. Of the 277 patients who were diagnosed with severe infection or sepsis in the emergency department, an infection was suspected in 124 (44.8%) patients, and sepsis was suspected in 31 (11.2%) patients by referring healthcare providers. Time to initiation of antibiotic treatment was shorter in patients where sepsis or infection had been suspected prior to arrival for both patients with severe infections (p = 0.022) and sepsis (p = 0.004). Given the well-described outcome benefits of early sepsis therapy, recognition of sepsis needs to be improved. Appropriate scores should be used as part of routine patient assessment to reduce the time to antibiotic administration and improve patient outcomes.