In this episode I’ll:
1. Discuss an article about antibiotic delays for septic patients.
2. Answer the drug information question “Can protease inhibitors be used in necrotizing fasciitis?”
3. Share a resource for ACPE CE credits.
Article
Delays From First Medical Contact to Antibiotic Administration for Sepsis
Lead author: Christopher Seymour
Published in Critical Care Medicine May 2017
Background
Every hour antibiotics are delayed for septic patients, the chance of mortality increases. The authors of this study sought to evaluate delays in antibiotic administration and in-hospital mortality among patients with community-acquired sepsis.
Methods
The study was a retrospective cohort involving 9 hospitals served by 21 emergency medical services agencies in southwestern Pennsylvania. All patients from 2010 to 2012 with an EMS encounter and community-acquired sepsis were included.
Results
2,683 patients had community-acquired sepsis. The in-hospital mortality rate was 11%. The median time from first medical contact to antibiotic administration was 4.2 hours. A delay of 0.52 hours was accounted for by prehospital care and a delay of 3.6 hours was accounted for by the emergency department. Only the total medical contact and emergency department delay were associated with increased in-hospital mortality.
Conclusion
The authors concluded:
Both total medical contact and emergency department delay in antibiotic administration are associated with in-hospital mortality in community-acquired sepsis.
Discussion
The most important question I think this article raises is: Should antibiotics be given in the prehospital setting for sepsis?
At first glance, it seems that giving prehospital antibiotics is not supported by this study. After all, the delay in the prehospital period was not statistically significant in terms of effects on mortality. But if the antibiotic were to be given in the ambulance, 100% of the emergency department delay is eliminated, and this delay was associated with increased mortality.
Can the judgment of who has sepsis and who doesn’t be made in the prehospital setting?
Should septic patients get their first antibiotic dose in the ambulance?
— Pharmacy Joe ?? (@PharmacyJoe) April 27, 2017
@PharmacyJoe Can a paramedic make that judgement? Looking fwd to tuning in — Ashish Advani (@aaadvani) April 27, 2017
Unfortunately, no validated, objective criteria exist for sepsis on presentation in the prehospital setting. Perhaps a combination of the qSOFA score and some physical findings may be combined to identify sepsis, but this would require further study.
Even if the selection of patients is appropriate, prehospital antibiotic administration would likely reduce the yield of blood cultures obtained in the emergency department. For many infections, this would not change the patient’s care. But for cases of endocarditis or meningitis, the reduced yield of cultures could mean extended courses of unnecessarily broad antibiotics.
I would love to see the authors of this study analyze the same cohort of patients to determine whether a scoring system for identification of sepsis in the prehospital setting is possible. Such a scoring system would then need to be validated in another cohort before applied.
A randomized trial examining ceftriaxone in the prehospital setting for sepsis appears to be underway.
Drug information question
Q: Can protease inhibitors be used in necrotizing fasciitis?
A: It’s a long shot – there is a patent on the idea but no published data.
I’ve never used this therapy for a patient with necrotizing fasciitis, but I did encounter the concept years ago when caring for a patient with a particularly nasty case of chest wall necrotizing fasciitis.
It is believed that proteolytic enzyme producing bacteria, such as Streptococci, Staphylococci and Escherichia coli organisms, to name a few, are generally responsible [for tissue destruction in necrotizing fasciitis].
The patent also states:
It has now been discovered that protease inhibitors, when given in suitable amounts, can be used to retard the affects of proteolytic enzymes produced by certain strains of necrotizing soft tissue infections, especially necrotizing fasciitis. The protease inhibitors retard the onset of such necrotizing infections by inhibiting the destructive effects of the proteolytic enzymes produced by Strep viridans and other such bacteria.
It is unclear to me whether the idea of using protease inhibitors for necrotizing fasciitis has been tested but not proven to work, or if the idea in this patent has never been tested. Perhaps the information in the patent would lead some clinicians to consider protease inhibitors as a “salvage therapy” in patients who appear to be certain to die from necrotizing fasciitis.
Resource
In conjunction with the Wegman’s School of Pharmacy St. John Fisher College, I’ve created a simple way for pharmacists to get ACPE credit from the podcast.
You can register for the CE programs at pharmacyjoe.com/ce. Just listen to a month’s worth of podcast episodes, then take a short quiz to obtain your ACPE credit. As of this writing, credits are available for the months of February and March 2017.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Nothing precludes the drawing of cultures in the pre-hospital phase of the septic patients care thus negating the argument that some patients would be subjected to unnecessarily long courses of antibiotics. A prospective, randomized study probably needs to be undertaken on the use of pre-hospital antibiotics before EMS systems widely adopt the practice.
Perhaps a validated tool to identify patients who should get antibiotics would be enough for some systems to start this practice.
All the more case to argue for an ED clinical pharmacist to be staffed in every busy emergency department. A trained ED Pharmacist (especially with an established sepsis protocol) would potentially reduce time to antibiotic administration and also assist in proper antibiotic selection.