Timing of antibiotics in septic patients: a prospective cohort study

Impact of metagenomics next-generation sequencing on etiological diagnosis and early outcomes in sepsis

BACKGROUND

Clinical implications of metagenomics next-generation sequencing (mNGS) in sepsis have not been fully evaluated. This study aimed to determine the diagnostic, therapeutic, and prognostic impacts of mNGS in sepsis.

METHODS

This multicenter prospective study was conducted at 19 sites in China from 2020 to 2021, and 859 adult patients hospitalized with sepsis were enrolled. The advantages, challenges, knowledge gaps and privacy risks of mNGS were carefully introduced to all participants, and participants chose on their own to either receive conventional microbiological test (CMT) alone (conventional-test-only group, n = 394) or receive mNGS test along with CMT (combined test group, n = 465). For prognostic analysis, the primary endpoint was 28-day mortality. Secondary endpoints included 7-day mortality and average per-day hospital cost. Inverse probability of treatment weighting was used to balance covariates between groups. Concurrent CMT and mNGS results from patients in the combined test group were used for diagnostic analyses. Therapeutic impact of mNGS was evaluated based on subsequent antibiotic adjustment.

RESULTS

Compared with composite reference standard, the positive percent agreement of mNGS among infected site samples was significantly higher than that of CMT (92.0% [95% CI, 88.7 to 94.5] vs. 51.1% [95% CI, 45.9 to 56.2], p < 0.001), while the negative percent agreement of mNGS was inferior to that of CMT (39.6% [95% CI, 29.5 to 50.4] vs. 69.2% [95% CI, 58.7 to 78.5], p < 0.001). The mNGS test identified causal microbes in 344 (74.0%) patients, and concomitant antibiotic changes occurred in 136 patients (29.2%). Death by day 7 occurred in 24 of 465 (5.2%) patients in the combined test group and in 34 of 394 (8.6%) patients in the conventional-test-only group (hazard ratio, 0.44 [95% CI, 0.26 to 0.77], p = 0.004). However, no significant difference in 28-day mortality was observed between two study groups (hazard ratio, 0.82 [0.56 to 1.20], p = 0.300).

CONCLUSIONS

The mNGS test of infected site samples exhibited 40% higher pathogen detection rate than CMT in patients with sepsis, which led to improved etiological diagnosis and tailored antibiotic therapy. Additional use of mNGS halved the risk of early death in 7 days, but did not improve 28-day survival in patients with sepsis.

TRIAL REGISTRATION

chictr.org.cn Identifier: ChiCTR2000031113. Registered 22 March 2020.

Early management of adult sepsis and septic shock: Korean clinical practice guidelines

BACKGROUND

Despite recent advances and global improvements in sepsis recognition and supportive care, mortality rates remain high, and adherence to sepsis bundle components in Korea is low. To address this, the Korean Sepsis Alliance, affiliated with the Korean Society of Critical Care Medicine, developed the first sepsis treatment guidelines for Korea based on a comprehensive systematic review and meta-analysis.

METHODS

A de novo method was used to develop the guidelines. Methodologies included determining key questions, conducting a literature search and selection, assessing the risk of bias, synthesizing evidence, and developing recommendations. The certainty of evidence and the strength of recommendations were determined using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Draft recommendations underwent internal and external review processes and public hearings. The development of these guidelines was supported by a research grant from the Korean Disease Control and Prevention Agency.

RESULTS

In these guidelines, we focused on early treatments for adult patients with sepsis and septic shock. Through the guideline development process, 12 key questions and their respective recommendations were formulated. These include lactate measurement, fluid therapies, target blood pressure, antibiotic administration, use of vasopressors and dobutamine, extracorporeal membrane oxygenation, and echocardiography.

CONCLUSIONS

These guidelines aim to support medical professionals in making appropriate decisions about treating adult sepsis and septic shock. We hope these guidelines will increase awareness of sepsis and reduce its mortality rate.

Getting Up to Speed: Rapid Pathogen and Antimicrobial Resistance Diagnostics in Sepsis

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Time to receive effective therapy is a primary determinant of mortality in patients with sepsis. Blood culture is the reference standard for the microbiological diagnosis of bloodstream infections, despite its low sensitivity and prolonged time to receive a pathogen detection. In recent years, rapid tests for pathogen identification, antimicrobial susceptibility, and sepsis identification have emerged, both culture-based and culture-independent methods. This rapid narrative review presents currently commercially available approved diagnostic molecular technologies in bloodstream infections, including their clinical performance and impact on patient outcome, when available. Peer-reviewed publications relevant to the topic were searched through PubMed, and manufacturer websites of commercially available assays identified were also consulted as further sources of information. We have reviewed data about the following technologies for pathogen identification: fluorescence in situ hybridization with peptide nucleic acid probes (Accelerate PhenoTM), microarray-based assay (Verigene®), multiplex polymerase chain reaction (cobas® eplex, BioFire® FilmArray®, Molecular Mouse, Unyvero BCU SystemTM), matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (Rapid MBT Sepsityper®), T2 magnetic resonance (T2Bacteria Panel), and metagenomics-based assays (Karius©, DISQVER®, Day Zero Diagnostics). Technologies for antimicrobial susceptibility testing included the following: Alfed 60 ASTTM, VITEK® REVEALTM, dRASTTM, ASTar®, Fastinov®, QuickMIC®, ResistellTM, and LifeScale. Characteristics, microbiological performance, and issues of each method are described, as well as their clinical performance, when available.

The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization

This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.

An observational study on the impact of overcrowding towards door-to-antibiotic time among sepsis patients presented to emergency department of a tertiary academic hospital

BACKGROUND

The latest Surviving Sepsis Campaign 2021 recommends early antibiotics administration. However, Emergency Department (ED) overcrowding can delay sepsis management. This study aimed to determine the effect of ED overcrowding towards the management and outcome of sepsis patients presented to ED.

METHODS

This was an observational study conducted among sepsis patients presented to ED of a tertiary university hospital from 18th January 2021 until 28th February 2021. ED overcrowding status was determined using the National Emergency Department Overcrowding Score (NEDOCS) scoring system. Sepsis patients were identified using Sequential Organ Failure Assessment (SOFA) scores and their door-to-antibiotic time (DTA) were recorded. Patient outcomes were hospital length of stay (LOS) and in-hospital mortality. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 26. P-value of less than 0.05 for a two-sided test was considered statistically significant.

RESULTS

Total of 170 patients were recruited. Among them, 33 patients presented with septic shock and only 15% (n = 5) received antibiotics within one hour. Of 137 sepsis patients without shock, 58.4% (n = 80) received antibiotics within three hours. We found no significant association between ED overcrowding with DTA time (p = 0.989) and LOS (p = 0.403). However, in-hospital mortality increased two times during overcrowded ED (95% CI 1-4; p = 0.041).

CONCLUSION

ED overcrowding has no significant impact on DTA and LOS which are crucial indicators of sepsis care quality but it increases overall mortality outcome. Further research is needed to explore other factors such as lack of resources, delay in initiating fluid resuscitation or vasopressor so as to improve sepsis patient care during ED overcrowding.

Early assessment of blood culture negativity as a potential support tool for antimicrobial stewardship

Objective

To assess whether 48-h negative blood culture (BC) bottles are still negative at the classic 120-h incubation endpoint and whether 48 h might be the time to make antimicrobial therapy decisions.

Methods

Data from the first collected bottles from bloodstream infection (BSI) episodes of single patients were retrospectively analyzed. Probabilities of bottles being negative at the classic endpoint were calculated from 0 to 120 h of incubation.

Results

Among BC-negative episodes (4018/4901 [82.0%]), most (2097/4018 (52.2%) occurred in medicine patients. At 48 h, probability was 100.0% (95% CI, 99.9-100.0) for all 4018 patients. Of these, 1244 (31.0%) patients remained on antibiotics until 120 h. Excluding 401 (32.2%) patients who received antibiotics for another (non-bloodstream) infection, 843 (67.8%) of 1244 patients could have merited early (48-h) discontinuation of antibiotics. Stopping treatment in these patients would have led to saving 5201 days of access (943 [18.1%] days), watch (3624 [69.7%] days), or reserve (634 [12.2%]) AWaRe groups' antibiotics, which correspond to 65.6% (5201/7928) of days of administered antibiotics in all 1244 patients.

Conclusion

As an early indicator of BC negativity, the 48-h endpoint could reliably support antimicrobial stewardship, but the clinical judgment remains imperative especially when BSI is highly suspected.

Effect of delayed antibiotic use on mortality outcomes in patients with sepsis or septic shock: A systematic review and meta-analysis

BACKGROUND

The use of antibiotics is essential in the treatment of sepsis and septic shock, and delaying their administration may impact patient mortality outcomes. However, there is currently a controversial debate surrounding this issue. In this meta-analysis, we aimed to explore the association between delayed antibiotic use and mortality in patients with sepsis and septic shock.

METHODS

A systematic search was conducted on PubMed, EMBASE, Web of Science, and Cochrane Library to identify relevant studies published from 2013 to 2023. These studies focused on patients with sepsis or septic shock and provided information on various antibiotic administration times and mortality rates. Two independent reviewers screened and extracted the data. The quality of each study was assessed using the Newcastle-Ottawa Scale, and the collected data were analyzed using STATA 15.1 software.

RESULTS

A total of 29 studies were included, consisting of 17 prospective cohort studies and 12 retrospective cohort studies. The meta-analysis showed that compared to administration of antibiotics within 1 h, each hour of delay in antibiotic administration increased the in-hospital mortality (IHM) (OR = 1.041, 95 % CI: 1.021-1.062), and ministration of antibiotics after 1 h increased the IHM (OR = 1.205, 95 % CI: 1.123-1.293). There was no significant change in the 28-day mortality (OR = 1.297, 95 % CI: 0.882-1.906), 90-day mortality (OR = 1.172, 95 % CI: 0.846-1.622), and 1-year mortality (OR = 0.986, 95 % CI: 0.422-2.303). Administration of antibiotics within 3 h may reduce the IHM (OR = 1.297, 95 % CI: 1.011-1.664, p = 0.041), while administration of antibiotics within 6 h showed no significant association with the IHM.

CONCLUSION

The administration of antibiotics beyond 1 h after emergency triage or disease identification is strongly associated with an increased IHM in patients with sepsis or septic shock, and each hour of delay in antibiotic administration may be associated with an increase in the IHM. Furthermore, the use of antibiotics identification beyond 3 h after emergency triage / sepsis or septic shock may also increase the IHM.

Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting

BACKGROUND

In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock.

METHODS

From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed.

RESULTS

Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95].

CONCLUSION

In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.

Effects of Vitamin D Deficiency on Sepsis

A prospective cohort study was conducted to evaluate the effect of vitamin D deficiency on sepsis. A total of 129 patients were enrolled. The median age was 74 years old, with a median SOFA score of 7; septic shock was observed in 60 patients. The median vitamin D level in the overall population was 13 ng/mL. A total of 96 patients had vitamin D deficiency, whereas 62 patients were described to have severe vitamin D deficiency. Severe vitamin D deficiency significantly increased the 14-day mortality (adjusted hazard ratio (aHR) 2.57; 95% confidence interval [CI]: 1.03-6.43; p = 0.043), 28-day mortality (aHR 2.28; 95% CI: 1.17-4.45; p = 0.016), and in-hospital mortality (aHR 2.11; 95% CI: 1.02-4.36; p = 0.044). In Kaplan-Meier analysis, the severe vitamin D deficiency group had significantly higher 14-day and 28-day mortality rates compared with the non-deficient group. Evaluating the vitamin D levels in sepsis patients may become necessary in an aging society. Severe vitamin D deficiency can independently affect poor prognosis related to sepsis. Further studies are needed to evaluate whether vitamin D supplementation in sepsis patients with vitamin D deficiency can help improve the prognosis of sepsis in addition to improving bone mineral metabolism.

Reduction of BSI associated mortality after a sepsis project implementation in the ER of a tertiary referral hospital

The emergency room (ER) is the first gateway for patients with sepsis to inpatient units, and identifying best practices and benchmarks to be applied in this setting might crucially result in better patient's outcomes. In this study, we want to evaluate the results in terms of decreased the in-hospital mortality of patients with sepsis of a Sepsis Project developed in the ER. All patients admitted to the ER of our Hospital from the 1st January, 2016 to the 31stJuly 2019 with suspect of sepsis (MEWS score ≥ of 3) and positive blood culture upon ER admission were included in this retrospective observational study. The study comprises of two periods: Period A: From the 1st Jan 2016 to the 31st Dec 2017, before the implementation of the Sepsis project. Period B: From the 1st Jan 2018 to the 31stJul 2019, after the implementation of the Sepsis project. To analyze the difference in mortality between the two periods, a univariate and multivariate logistic regression was used. The risk of in-hospital mortality was expressed as an odds ratio (OR) and a 95% confidence interval (95% CI). Overall, 722 patients admitted in ER had positive BC on admissions, 408 in period A and 314 in period B. In-hospital mortality was 18.9% in period A and 12.7% in period B (p = 0.03). At multivariable analysis, mortality was still reduced in period B compared to period A (OR 0.64, 95% CI 0.41-0.98; p = 0.045). Having an infection due to GP bacteria or polymicrobial was associated with an increased risk of death, as it was having a neoplasm or diabetes. A marked reduction in in-hospital mortality of patients with documented BSI associated with signs or symptoms of sepsis after the implementation of a sepsis project based on the application of sepsis bundles in the ER.

Systematic Review on the Effects of Prompt Antibiotic Treatment on Survival in Septic Shock and Sepsis Patients in Different Hospital Settings

This study aims to determine the impact of prompt administration of antibiotics in evaluating the prognosis of patients with septic shock or sepsis. On January 1, 2022, we searched the Cochrane Library, EMBASE, and MEDLINE databases for English-language articles regarding when antibiotics should be administered to patients with septic shock or sepsis. These articles were required to be published between 2010 and 2021. The primary objective was sudden or expected death from any cause at a specified time. In the study, 154,330 patients from 35 sepsis trials were included. In 19 trials, the effectiveness of antibiotics administered to 20,062 patients was evaluated. Of those, 16,652 received the correct medications. In 24 studies, the length of time it took to administer antibiotics was associated with an increased mortality rate. In fourteen studies, the time limits associated with patient outcomes ranged from 1 to 125 minutes to three to six hours. In eight studies, there were hourly delays, and in two, the time it took to receive an antibiotic played a role. Separately analyzed, the outcomes for septic shock (12,756 patients in 11 trials) and sepsis (24,282 patients in six studies) were identical. Two-thirds of sepsis studies discovered a correlation between early antibiotic treatment and the patient's prognosis. However, antimicrobial timing metrics varied significantly between studies, and there were no clear time limits.

Association Between Time to Appropriate Antimicrobial Treatment and 30-day Mortality in Patients With Bloodstream Infections: A Retrospective Cohort Study

BACKGROUND

Effective antimicrobial treatment is key for survival in bloodstream infection (BSI), but the impact of timing of treatment remains unclear. Our aim was to assess the association between time to appropriate antimicrobial treatment and 30-day mortality in BSI patients.

METHODS

This was a retrospective cohort study using electronic health record data from a large academic center in Sweden. Adult patients admitted between the years 2012 and 2019, with onset of BSI at the emergency department or general wards, were included. Pathogen-antimicrobial drug combinations were classified as appropriate or inappropriate based on reported in vitro susceptibilities. To avoid immortal time bias, the association between appropriate therapy and mortality was assessed with multivariable logistic regression analysis at pre-specified landmark times.

RESULTS

We included 10 628 BSI-episodes, occurring in 9192 unique patients. The overall 30-day mortality was 11.8%. No association in favor of a protective effect between appropriate therapy and mortality was found at the 1, 3 and 6 hours landmark after blood culture collection. At 12 hours, the risk of death increased with inappropriate treatment (adjusted odds ratio 1.17 [95% confidence interval {CI}, 1.01-1.37]) and continued to increase gradually at 24, 48, and 72 hours. Stratifying by high or low SOFA score generated similar odds ratios, with wider confidence intervals.

CONCLUSIONS

Delays in appropriate antimicrobial treatment were associated with increased 30-day mortality after 12 hours from blood culture collection, but not at 1, 3, and 6 hours, in BSI. These results indicate a benchmark for providing rapid microbiological diagnostics of blood cultures.

Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock

OBJECTIVES

This study aims to investigate the association between the 30-day mortality in patients with septic shock (SS) and a prehospital bundle of care completion, antibiotic therapy administration, and hemodynamic optimization defined as a fluid expansion of at least 10 mL.kg-1.hr-1.

DESIGN

To assess the association between prehospital BUndle of Care (BUC) completion and 30-day mortality, the inverse probability treatment weighting (IPTW) propensity method was performed.

SETTING

International guidelines recommend early treatment implementation in order to reduce SS mortality. More than one single treatment, a bundle of care, including antibiotic therapy and hemodynamic optimization, is more efficient.

PATIENTS

From May 2016 to March 2021, patients with SS requiring prehospital mobile ICU (mICU) intervention were retrospectively analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among the 529 patients with SS requiring action by the mICU enrolled in this study, 354 (67%) were analyzed. Presumed pulmonary, digestive, and urinary infections were the cause of the SS in 49%, 25%, and 13% of the cases, respectively. The overall 30-day mortality was 32%. Seventy-one patients (20%) received prehospital antibiotic therapy and fluid expansion. Log binomial regression weighted with IPTW resulted in a significant association between 30-day mortality and prehospital BUC completion (respiratory rate [RR] of 0.56 [0.33-0.89]; p = 0.02 and adjusted RR 0.52 [0.27-0.93]; p = 0.03).

CONCLUSIONS

A prehospital bundle of care, based on antibiotic therapy and hemodynamic optimization, is associated with a 30-day mortality decrease among patients suffering from SS cared for by an mICU.

Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients

Background

Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage.

Methods

From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality.

Results

Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h⁻¹, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10^–3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10^–3.

Conclusion

In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.

Adequacy of probabilistic prehospital antibiotic therapy for septic shock

BACKGROUND

Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown.

METHODS

From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed.

RESULTS

Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10^-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93].

CONCLUSIONS

Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Time to administration of antibiotics and mortality in sepsis

OBJECTIVE

To examine the association between delay of antibiotic treatment and 28-day mortality in a study of septic patients identified by the Sepsis-3 criteria.

METHODS

A prospective observational cohort study of patients (≥ 18 years) with sepsis admitted to a Danish emergency department between October 2017 and March 2018. The interval between arrival to the ED and first delivery of antibiotics was used as time to antibiotic treatment (TTA). Logistic regression was used in the analysis of the association between TTA and mortality adjusted for potential confounding.

RESULTS

A total of 590 patients, median age 74.2 years, were included. Overall 28-day mortality was 14.6% (95% confidence interval [CI], 11.8-17.7). Median TTA was 4.7 hours (interquartile range 2.7-8.1). The mortality in patients with TTA ≤1 hour was 26.5% (95% CI, 12.8-44.4), and 15.3% (95% CI, 9.8-22.5), 10.5% (95% CI, 6.6-15.8), and 12.8 (95% CI, 7.3-20.1) in the timespans 1-3, 3-6, and 6-9 hours, respectively, and 18.8% (95% CI, 12.0-27.2) in patients with TTA >9 hours. With patients with lowest mortality (TTA timespan 3-6 hours) as reference, the adjusted odds ratio of mortality was 4.53 (95% CI, 1.67-3.37) in patients with TTA ≤1 hour, 1.67 (95% CI, 0.83-3.37) in TTA timespan 1-3 hours, 1.17 (95% CI, 0.56-2.49) in timespan 6-9 hours, and 1.91 (95% CI, 0.96-3.85) in patient with TTA >9 hours.

CONCLUSIONS

The adjusted odds of 28-day mortality were lowest in emergency department (ED) patients with sepsis who received antibiotics between 1 and 9 hours and highest in patients treated within 1 and >9 hours after admission to the ED.

Impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis and septic shock

OBJECTIVES

To review the impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis or septic shock.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Library, Web of Science, Open-SIGLE databases, ClinicalTrials.gov and the metaRegister of Controlled Trials on July 27, 2020 for relevant studies on the timing of antibiotic therapy in adult patients with sepsis or septic shock. The primary outcome measure was all-cause crude or adjusted mortality at reported time points.

RESULTS

We included 35 sepsis studies involving 154,330 patients. Nineteen studies (54%) provided information on the appropriateness of antibiotic therapy in 20,062 patients of whom 16,652 patients (83%) received appropriate antibiotics. Twenty-four studies (68.6%) reported an association between time-to-antibiotics and mortality. Time thresholds associated with patient's outcome varied considerably between studies consisting of a wide range of time cutoffs (1 h, 125 min, 3 h or 6 h) in 14 studies, hourly delays (derived from the analyses of time intervals ranging from to 1 to 24 h) in 8 studies or time-to-antibiotic in 2 studies. Analyses of subsets of studies that focused on patients with septic shock (11 studies, 12,756 patients) or with sepsis (6 studies, 24,281 patients) yielded similar results.

CONCLUSIONS

While two-thirds of sepsis studies reported an association between early administration of antibiotic therapy and patient outcome, the time-to-antibitiocs metrics varied significantly across studies and no robust time thresholds emerged.

Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock

INTRODUCTION

Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS.

METHODS

From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage.

RESULTS

Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01).

CONCLUSION

In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.

Evaluation of Microbiological Performance and the Potential Clinical Impact of the ePlex® Blood Culture Identification Panels for the Rapid Diagnosis of Bacteremia and Fungemia

Molecular rapid diagnostic assays associated with antimicrobial stewardship have proven effective for the early adaptation of empiric therapy in bloodstream infections. The ePlex^® BCID (GenMark Diagnostics) Panels allow identification of 56 bacteria and fungi and 10 resistance genes in 90 min directly from positive blood cultures. We prospectively evaluated 187 sepsis episodes at Grenoble University Hospital and retrospectively analyzed the cases to measure the potential clinical impact of the ePlex BCID results. Identification of all pathogens was obtained for 164/187 (88%) bloodstream infections with 100% detection of antimicrobial resistance genes (17 bla_CTX-M , 1 vanA, and 17 mecA genes). Only 15/209 (7%) strains were not covered by the panels. Sensitivity for detection of micro-organisms targeted by the RUO BCID-GP, BCID-GN, and BCID-FP Panels was respectively 84/84 (100%), 103/107 (96%), and 14/14 (100%). Interestingly, accurate identification of all pathogens was achieved in 15/17 (88%) polymicrobial samples. Retrospective analysis of medical records showed that a modification of antimicrobial treatment would have been done in 45% of the patients. Treatment modifications would have been an optimization of empiric therapy, a de-escalation or an escalation in respectively 16, 17, and 11% of the patients. Moreover, 11% of the samples were classified as contaminants or not clinically relevant and would have led to early de-escalation or withdrawal of any antibiotic. Detection of resistance genes in addition to identification alone increased escalation rate from 4 to 11% of the patients. Absence of the ePlex result was considered a lost opportunity for therapy modification in 28% of patients.

Antimicrobial Therapy and Antimicrobial Stewardship in Sepsis

Since sepsis was first defined, sepsis management has remained challenging. To improve mortality rates for sepsis and septic shock, an accurate diagnosis and prompt administration of appropriate antibiotics are essential. The goals of antimicrobial stewardship are to achieve optimal clinical outcomes and to ensure cost-effectiveness and minimal unintended consequences, such as toxic effects and development of resistant pathogens. A combination of inadequate diagnostic criteria for sepsis and time pressure to provide broad-spectrum antimicrobial therapy remains an obstacle for antimicrobial stewardship. Efforts such as selection of appropriate empirical antibiotics and de-escalation or determination of whether or not to stop antibiotics may help to improve a patient's clinical prognosis as well as the successful implementation of antimicrobial stewardship.