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Does Antibiotic Under 1 Hour Impact Mortality?

July 30, 2020

Written by Clay Smith

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There does not appear to be a mortality benefit to antibiotic administration <1 hour vs < 3 hours for patients with severe infection.

Why does this matter?
Yesterday we learned that delayed antibiotics were associated with increased mortality. But how much delay really matters? There is a push toward giving antibiotics within the first hour. And there has been forceful pushback against such a mandate. What does the evidence say?

Shotgun antibiotics? Probably not a good idea…
This was a systematic review of 13 studies after the year 2000, almost 34,000 total patients, that included adult patients with severe sepsis or septic shock and measured time to antibiotics from 0-3 hours. There was no difference in mortality for immediate (<1 hour) vs early (<3 hours) antibiotics, OR 1.09 (95%CI 0.98 to 1.21). No subgroup showed benefit. The subgroup with severe sepsis showed possible harm with immediate antibiotics, OR 1.29 (95%CI 1.09 to 1.53). Overall, quality of evidence was low, and most studies were retrospective. There were only 2 studies that were contained in both this and the CHEST meta-analysis from yesterday. They were looking at different things. Most of the included studies in this analysis were based in the ED, as opposed to yesterday, with patients already admitted to the hospital or ICU. This evidence does not lend support to the sepsis mandate to give antibiotics in under an hour from ED arrival. There may be harm associated with a 1-hour-sepsis-bundle approach, in antibiotic overuse and unnecessary volume expansion. In addition, subsequent studies have found that even those who want to comply and give antibiotics in under an hour find it is not feasible.

Outcome of Immediate Versus Early Antibiotics in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis. Ann Emerg Med. 2020 Jun 24:S0196-0644(20)30337-1. doi:10.1016/j.annemergmed.2020.04.042.

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What are your thoughts?