Prehospital Care and Emergency Department Door-to-Antibiotic Time in Sepsis

The burden and prognostic significance of suspected sepsis in the prehospital setting: A state-wide population-based cohort study

OBJECTIVE

Despite high in-hospital mortality, the epidemiology of prehospital suspected sepsis presentations is not well described. This retrospective cohort study aimed to quantify the burden of such presentations, and to determine whether such a diagnosis was independently associated with longer-term mortality.

METHODS

Retrospective, observational population-based cohort study examining all adult prehospital presentations in Victoria, between January 2015 and June 2019, who required subsequent in-hospital assessment. Linked data were extracted from clinical and administrative datasets. Demographics, illness severity, prehospital treatment and mortality were compared between prehospital suspected sepsis and non-sepsis patients. Multivariable logistic regression was used to determine the adjusted association between prehospital assessment (suspected sepsis vs non-sepsis) and 6-month mortality.

RESULTS

A total of 1 218 047 patients were included. The age-adjusted incidence rate of prehospital suspected sepsis was 65 cases per 100 000 person-years. Those with prehospital suspected sepsis were older (74 vs 62 years), more frequently male (55% vs 47%), with greater physiological derangement. Intravenous cannulas were more often inserted prehospital (60% vs 29%). Crude in-hospital mortality was 6.5-fold higher in the prehospital suspected sepsis group (11.8% vs 1.8%), and by 6 months, 22.6% had died. After adjustment for demographics, illness severity, comorbidity, treatment and hospital location, a diagnosis of prehospital suspected sepsis was associated with a 35% higher likelihood of 6-month mortality (OR 1.35, 95% CI 1.29-1.41).

CONCLUSIONS

The burden of prehospital suspected sepsis in the Australian setting is significant, with paramedics identifying patients at high-risk of poor longer-term outcomes. This implies the need to consider improved care pathways for this highly vulnerable group.

Impact of Prehospital Antibiotics on in-Hospital Mortality in Emergency Medical Service Patients with Sepsis

Background

Sepsis is a life-threatening medical condition that requires early recognition and timely management to improve patient outcomes and reduce mortality rates. Administering antibiotics in the prehospital setting can be effective to reduce the time to antibiotic therapy, which may be crucial for sepsis patients. However, the impact of prehospital antibiotics on mortality in sepsis patients remains uncertain, and the current evidence to support this practice in middle-income countries is particularly limited.

Methods

This was a single-center, retrospective-prospective cohort study aimed at determining the impact of prehospital antibiotics on in-hospital mortality rates among adult patients with sepsis. The study included patients who received care from the advanced level of Emergency Medical Service between June 2020 and October 2022 and compared the mortality rates of patients who received prehospital antibiotics with those of their counterparts who did not.

Results

In this study, 180 patients with a mean age of 71.6 ± 15.7 years were included, of whom 68.9% experienced respiratory infections. The results demonstrated that the prehospital antibiotic group had a significantly lower in-hospital mortality rate (32.2%) than the non-prehospital antibiotic group (47.8%; p=0.034). After adjusting for confounding factors, the odds ratio was 0.304 (95% CI: 0.11, 0.82; p=0.018), indicating a 69.6% lower incidence of in-hospital mortality in the prehospital antibiotic group. Furthermore, the prehospital antibiotic group received antibiotics significantly earlier (16.0 ± 7.4 minutes) than the non-prehospital group (50.9 ± 29.4 minutes; p<0.001).

Conclusion

This study provides evidence to support the administration of antibiotics to sepsis patients in the prehospital setting, as this practice can reduce mortality rates. However, larger, multicenter studies are required to confirm these findings and to further investigate the potential benefits of prehospital antibiotics in improving patient outcomes.

Fast Track Diagnostic Tools for Clinical Management of Sepsis: Paradigm Shift from Conventional to Advanced Methods

Sepsis is one of the deadliest disorders in the new century due to specific limitations in early and differential diagnosis. Moreover, antimicrobial resistance (AMR) is becoming the dominant threat to human health globally. The only way to encounter the spread and emergence of AMR is through the active detection and identification of the pathogen along with the quantification of resistance. For better management of such disease, there is an essential requirement to approach many suitable diagnostic techniques for the proper administration of antibiotics and elimination of these infectious diseases. The current method employed for the diagnosis of sepsis relies on the conventional culture of blood suspected infection. However, this method is more time consuming and generates results that are false negative in the case of antibiotic pretreated samples as well as slow-growing microbes. In comparison to the conventional method, modern methods are capable of analyzing blood samples, obtaining accurate results from the suspicious patient of sepsis, and giving all the necessary information to identify the pathogens as well as AMR in a short period. The present review is intended to highlight the culture shift from conventional to modern and advanced technologies including their limitations for the proper and prompt diagnosing of bloodstream infections and AMR detection.

[Sepsis in out-of-hospital emergency medicine]

Background

Sepsis is a challenge in emergency medicine, as this life-threatening organ dysfunction, caused by a dysregulated host response to an infection, presents manifold and therefore is often recognized too late.

Objectives

Recently published surviving sepsis campaign and German S3 guidelines provide recommendations for diagnosis and therapy of sepsis in an in-hospital or intensive care setting, but do not particularly address out-of-hospital emergency medical care. We aim to work out the evidence base with regard to the out-of-hospital care of patients with suspected sepsis and to derive treatment recommendations for emergency medical services.

Conclusions

Therapy of sepsis and septic shock is summarized in bundles, whereby the first bundle should ideally be completed within the first hour-in analogy to "golden hour" concepts in other emergency medical entities, such as trauma care. In the out-of-hospital setting, therapy focuses on securing vital parameters, according to the ABCDE scheme, with a particular focus on volume therapy. Further procedures within the 1 h bundle, such as lactate measurement, obtaining microbiological samples, and starting an anti-infective therapy, are broadly available in hospital only. The aim is to control the site of infection as soon as possible. Therefore, an appropriate designated hospital should be chosen carefully and informed in advance, in order to initiate and pave the way for further clinical diagnostic and treatment paths. Moreover, structured and target-oriented handovers, as well as regular training, are required.

Evidence for the Application of Sepsis Bundles in 2021

Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.

Antibiotic treatment in patients with sepsis: a narrative review

Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.

Institution of an emergency department "swarming" care model and sepsis door-to-antibiotic time: A quasi-experimental retrospective analysis

Background

Prompt sepsis treatment is associated with improved outcomes but requires a complex series of actions by multiple clinicians. We investigated whether simply reorganizing emergency department (ED) care to expedite patients’ initial evaluation was associated with shorter sepsis door-to-antibiotic times.

Methods

Patients eligible for this retrospective study received IV antibiotics and demonstrated acute organ failure after presenting to one of three EDs in Utah. On May 1, 2016, the intervention ED instituted “swarming” as the default model for initial evaluation of all mid- and low-acuity patients. Swarming involved simultaneous patient evaluation by the ED physician, nurse, and technician followed by a team discussion of the initial care plan. Care was unchanged at the two control EDs. A 30-day wash-in period separated the baseline (May 16, 2015 to April 15, 2016) and post-intervention (May 16, 2016 to November 15, 2016) analysis periods. We conducted a quasi-experimental analysis comparing door-to-antibiotic time for sepsis patients at the intervention ED after versus before care reorganization, applying difference-in-differences methods to control for trends in door-to-antibiotic time unrelated to the studied intervention and multivariable regression to adjust for patient characteristics.

Results

The analysis included 3,230 ED sepsis patients, including 1,406 from the intervention ED. Adjusted analyses using difference-in-differences methods to control for temporal trends unrelated to the studied intervention revealed no significant change in door-to-antibiotic time after care reorganization (-7 minutes, 95% CI -20 to 6 minutes, p = 0.29). Multivariable pre/post analyses using data only from the intervention ED overestimated the magnitude and statistical significance of outcome changes associated with ED care reorganization.

Conclusions

Implementation of an ED care model involving parallel multidisciplinary assessment and early team discussion of the care plan was not associated with improvements in mid- and low-acuity sepsis patients’ door-to-antibiotic time after accounting for changes in the outcome unrelated to the studied intervention.

An approach to antibiotic treatment in patients with sepsis

Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, which is time-dependent and associated with unacceptably high mortality. Thus, when treating suspicious or confirmed cases of sepsis, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Optimizing antibiotic use is essential to ensure successful outcomes and to reduce adverse antibiotic effects, as well as preventing drug resistance. All likely pathogens involved should be considered to provide an appropriate antibiotic coverage. Clinicians must investigate on the previous risk of multidrug-resistant (MDR) pathogens, and the principle of individualized dosing should replace the principle of standard dosing. The loading dose is an initial higher dose of an antibiotic for all patients, yet an individualized treatment approach for further doses should be implemented according to pharmacokinetics (PK)/pharmacodynamics (PD) and the presence of renal/liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring (TDM) can help to achieve therapeutic levels of antimicrobials. Reevaluation of duration and appropriateness of treatment at regular intervals are also necessary. De-escalation and shortened courses of antimicrobials must be considered for most patients, except in some justified circumstances. Leadership, teamwork, antimicrobial stewardship (AS) frameworks, guideline’s recommendations on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients’ quality of care.

Emergency Medical Services Care and Sepsis Trajectories

Objective: Many sepsis patients receive initial care from prehospital Emergency Medical Services (EMS). While earlier sepsis care improves outcomes, the characteristics, care and outcomes of those treated by EMS versus those arriving directly to an emergency department (ED) are currently not detailed. We sought to determine differences in hospital presentation, course and outcomes between EMS and non-EMS patients enrolled in the Protocolized Care of Early Septic Shock (ProCESS) trial. Methods: We performed a secondary analysis of ProCESS, which studied ED patients with septic shock. EMS care was the primary exposure. We determined differences in demographics, clinical features, interventions and hospital course between EMS and non-EMS patients. Using mixed models, we determined the association between EMS care and 60-day mortality. Results: Among 1,341 patients, 826 (61.6%) received initial EMS care. EMS patients were older, more likely to be black (OR 1.49, 95% CI 1.14-1.95) or nursing home residents (5.57, 3.61-8.60), and more likely to have chronic respiratory disease (1.36, 1.04-1.78), cerebral vascular disease (1.56; 1.04-2.33), peripheral vascular disease (2.02; 1.29-3.16), and dementia (3.53; 2.04-6.10). EMS patients were more likely to present with coma (4.48; 2.53-7.96) or elevated lactate (1.30; 1.04-1.63), and to receive mechanical ventilation in the ED (7.16; 4.34-11.79). There were no differences in infection source or total intravenous fluids. Initial differences in vasopressor use (1.66; 1.22-2.26) resolved at 6 hours (1.18; 0.94-1.47). Initial differences in APACHE II (EMS 21.8 vs. non-EMS 19.0) narrowed by 48 hours (17.9 vs. 16.3, [EMS X time] interaction p = 0.003). Although EMS patients exhibited higher 60-day mortality, after adjustment for confounders, this association was not significant (1.09, 95% CI: 0.78-1.55). Conclusions: While EMS sepsis patients presented with worse chronic, nonmodifiable characteristics and higher acuity than non-EMS patients, differences in acuity narrowed after initial hospital care. Despite having higher illness burden, EMS patients did not have worse adjusted short-term mortality.

Individualized antibiotic therapy in the treatment of severe infections

Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.

[Consensus document for sepsis code implementation and development in the Community of Madrid]

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.