Door-to-Antibiotic And Mortality in Sepsis

June 24, 2019

Written by Thomas Davis

Spoon Feed
Mortality was higher when door-to-antibiotic time was > 3 h. However, there was no difference when comparing mortality in those given antibiotics within the first hour to those after the first hour.  

Why does this matter?
The Surviving Sepsis Campaign continues to push for faster administration of antibiotics through its 1-hour bundle. Those guidelines were met with strong criticism from emergency medicine physicians, who were not given a chance to contribute to the development of these guidelines. Thankfully, the PHANTASi trial has made a strong case through randomized data that at some point faster does not equal better. How will this large cohort analysis shape the debate?

A retrospective spin on sepsis
This was a retrospective cohort study analyzing over 10,000 patients from both academic and community hospitals in Utah. Sepsis was defined using the Sepsis-3 definition, namely a SOFA score at least two points above a patient’s baseline. This means that these patients were sicker than those with SIRS+ sepsis. Therefore, they were more likely to benefit from timely administration of antibiotics than the patients American hospitals usually label as screening positive for sepsis. Unsurprisingly, more severely ill patients received antibiotics sooner. As a result, crude 1-year mortality rates were higher in those receiving antibiotics within 3 hours. After adjustment, delayed antibiotic administration was associated with increased mortality when comparing door-to-antibiotic time of > 3h vs < 3h (aOR 1.27; 95% CI, 1.13-1.43; P < 0.001). However, there was no association when comparing antibiotics < 1h vs > 1h. The authors did find that there was a 10% increase in the odds of 1-year mortality with each hour delay in antibiotic administration (95% CI, 5% – 14%; p < 0.001). Despite their being no discernible benefit to antibiotic administration within 1 hr of ED arrival, the authors used this hourly trend to make a backdoor argument that door-to-antibiotic initiation of < 1.5 hours would avoid one death for every 61 patients. Sounds like some spin to me!

Source
ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis. Chest. 2019 May;155(5):938-946. doi: 10.1016/j.chest.2019.02.008. Epub 2019 Feb 16.

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Reviewed by Clay Smith