Early Antibiotics Reduce Mortality in Septic Patients

Fran Lowry

January 24, 2011

January 24, 2011 (San Diego, California) — Starting antibiotic therapy as soon as possible after hospital admission for patients with sepsis improves mortality, even after adjustment for the severity of illness, researchers reported here at the Society of Critical Care Medicine 40th Critical Care Congress.

"In the cardiac world, time is muscle, and they have a door-to-balloon time," John Showalter, MD, from Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania, told Medscape Medical News in an interview at his poster. "The same principle should be working here with septic patients. If they had [a myocardial infarction], you would act really quickly to get them to the cath lab. When you think it's sepsis, you have to act quickly and get them antibiotics."

Dr. Showalter explained that the rationale for doing this study came after he and his colleagues noticed that sepsis mortality in their hospital was higher than the national average.

He and his team analyzed data from the charts of 780 patients 18 years and older with a primary billing diagnosis of sepsis, based on ICD-9 codes, between July 1, 2007 and June 30, 2010. Patients either came to the emergency department or were directly admitted to the hospital by their family physician.

Specifically, the researchers looked at information about severity of sepsis on presentation, timing of the first antibiotic, timing of the first fluid bolus, and modified Acute Physiology and Chronic Health Evaluation (APACHE) II criteria.

Dr. Showalter reported that there was an 88% increase in mortality in patients who received antibiotics 6 hours after arrival, compared with those who received antibiotics within 2 hours.

Administering the first intravenous antibiotic within 2 to 6 hours of arrival, compared with administering them within 2 hours of arrival, had an odds ratio for mortality of 1.27 (95% confidence interval [CI], 0.73 to 2.20; P = 0.39). Administration of intravenous antibiotics more than 6 hours after arrival, compared with administration within 2 hours, had an odds ratio for mortality of 1.88 (95% CI, 1.04 to 3.38, P = .04).

In addition, administration of a fluid bolus more than 3 hours after a patient's arrival had an odds ratio for mortality of 1.45 (95% CI, 0.90 to 2.35; P = .13), compared with administration less than 3 hours after arrival.

"We are not assuming that everybody will need an antibiotic, just people who you feel clinically have an infection. It's not across the board. It's really early identification of sepsis, which involves early suspicion and then 2 of the 4 [systemic inflammatory response syndrome] criteria, which are hemodynamic criteria, temperature, respiratory rate, and red blood cell count," Dr. Showalter noted.

Elizabeth Raitz Cowboy, MD, medical director of Advanced ICU Care, in St. Louis, Missouri, agreed that prompt treatment is key.

"Sepsis has a golden-hour-of-treatment window," she told Medscape Medical News. "Several studies have shown that the more rapidly we deliver correct broad spectrum antibiotics to the patient, the more likely they are to survive. For every hour we delay delivery of antibiotics, we increase mortality 6%," she explained.

Weighing in with his opinion, Richard H. Savel, MD, associate professor of clinical medicine and neurology at the Albert Einstein College of Medicine in the Bronx, New York, said that it was comforting to see "yet another study indicating that earlier is better when it comes to the management of patients with severe sepsis syndrome and septic shock."

Dr. Savel pointed out that the study was limited because it was retrospective, adding that the results "are not particularly novel."

Nevertheless, he noted, "this multivariate logistic regression analysis clearly demonstrates that early aggressive management, including fluid boluses and antibiotics, appears to be associated with improved outcomes."

Dr. Showalter, Dr. Cowboy, and Dr. Savel have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 40th Critical Care Congress: Abstract 704. Presented January 18, 2011.