In this episode, I’ll discuss whether immediate vs early antibiotic administration improves outcomes in severe sepsis.
For patients with severe sepsis, it is logical to start antibiotic therapy as soon as possible. This concept is supported by studies that show increases in mortality for every hour that antibiotic therapy is delayed.
This, in turn, has led to the development of quality metrics and guidelines defining goals for administering antibiotics within 1 hour as described in the SCCM Hour-1 bundle.
A recent systematic review and meta-analysis published in Annals of Emergency Medicine sought to analyze the effect of immediate (0 to 1 hour after onset) versus early (1 to 3 hours after onset) antibiotics on mortality in patients with severe sepsis or septic shock.
A total of 13 studies representing over 33,000 patients were included. In the pooled analysis, there was not a significant difference in mortality between the immediate and early antibiotic groups. When only severe sepsis studies were included, there was a higher mortality in the immediate antibiotic group (odds ratio 1.29).
The authors concluded:
We found no difference in mortality between immediate and early antibiotics across all patients. Although the quality of evidence across studies was low, these findings do not support a mortality benefit for immediate compared with early antibiotics across all patients with sepsis.
While most severe sepsis patients can and should be identified and treated with antibiotics immediately, there will always be a small cohort of patients with atypical or confusing presentations. In these patients, the imposition of a 1-hour antibiotic requirement may lead to hasty and unwise clinical decisions. This meta-analysis demonstrates that in such patients, taking the time for further clinical investigation with a goal of identifying and administering antibiotics within 3 rather than 1 hour has no impact on mortality outcomes.
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Unfortunately in medicine now a days we treat numbers, not people. I do agree with all of your points yet would like to suggest the following:
– I believe there is evidence showing that earlier administration of abx in patients that are really really sick yields improved mortality.
– In some of the sepsis trials there was a critical care fellow that came down to ‘facilitate’ (assist 😉 in the treatment arm thereby indirectly favoring improved pt care. That effect could explain previous findings.
– Ash