An increased risk for progression to septic shock was found to be associated with delayed administration of antibiotics among patients admitted to the emergency department (ED) with suspected sepsis, according to results of a retrospective observational cohort study published in Chest.
Between March 2007 and March 2020, investigators collected data on adults admitted to the ED with an infection suggestive of sepsis who were started on antibiotics within 24 hours of triage. Patients diagnosed with septic shock on ED admission were excluded, as well as those who were started on antibiotics more than 24 hours after ED admission. The investigators recorded the time of first administration of both antibiotics and broad-spectrum antibiotics for each patient, as well as the duration of time to antibiotics administration from ED admission. Progression to septic shock was defined as vasopressor infusion initiated within 3 hours of triage. The investigators performed univariate and multivariate logistic regression analyses to predict progression to septic shock.
Among a total of 74,114 patients included in the analysis, the mean age was 53.4 years and 57.5% were women.
Overall, a total of 5510 (7.4%) patients progressed to septic shock. Of these patients, the mean age was 59.2 years, 46.6% were women, and 88% received antibiotics within the first 5 hours of ED admission. The greatest increase in the percentage of patients who progressed to septic shock occurred among those who received antibiotics within the first 5 hours of triage. Of note, more than 90% of broad-spectrum antibiotics administered were piperacillin plus tazobactam and ceftriaxone.
Results of the univariate logistic regression analysis showed that time to initial antibiotic administration was associated with progression to septic shock (odds ratio [OR], 1.014; 95% CI, 1.008-1.021; P <.001). The multivariate logistic model also showed that time to initial antibiotic administration was associated with progression to septic shock (OR, 1.03; 95% CI, 1.02 to 1.04; P <.001). The investigators found that if time to initial antibiotics administration occurred more than 3 hours after ED admission, the OR for progression to septic shock was 1.17 (95% CI, 1.07-1.29; P =.001). After adjustment for illness severity, the model showed that for each hour the first administration of antibiotics was delayed, there was a 4% increase in the risk for progression to septic shock, up to 24 hours from triage.
Although patients with positive quick Sequential Organ Failure Assessment (qSOFA) results received antibiotics earlier than patients with positive Systemic Inflammatory Response Syndrome (SIRS) scores (P <.05), the median time to septic shock was significantly decreased among those with positive qSOFA results at triage vs those with positive SIRS scores at triage (P <.05).
This study was limited by the inability to determine the circumstances that caused delayed administration of antibiotics, and the lack of symptom data from patients with suspected sepsis. The investigators also were unable to assess the appropriateness of the type of antibiotics administered.
In regard to the study findings, the investigators concluded that there is a “…need for more sophisticated means of detecting infection early, such as via machine learning and artificial intelligence, especially among patients who seek care with less overt signs or symptoms [suggestive] of sepsis.”
Bisarya R, Song X, Salle J, Liu M, Patel A, Simpson SQ. Antibiotic timing and progression to septic shock among patients in the ED with suspected infection. Chest. 2022;161(1):112-120. doi:10.1016/j.chest.2021.06.029