Written by Jonathan Brewer
One-third of patients that were empirically treated with broad-spectrum antibiotics for suspected sepsis in the ED were eventually found to have viral or noninfectious etiologies. This potential overuse of antibiotics may contribute to antibiotic resistance and has important implications for guidelines and quality measures supporting immediate empiric antibiotics for suspected sepsis.
Why does this matter?
Often, we are notified that a patient has “activated sepsis criteria,” but what does this really mean? Does this mean that every patient with SIRS criteria truly has life-threatening organ dysfunction due to a dysregulated host response to infection? Recent literature would argue against that. I can tell you that I personally would activate “sepsis criteria” after running a few miles, but does this mean that I’ve developed florid bacteremia?
“Should I give the Vosyn?”
In this study, 300 random patients with suspected serious bacterial infection (SBI) were retrospectively selected across four Massachusetts Emergency Departments between June 2015 and June 2018. Patients were included in this study if there was suspicion for SBI, blood cultures were drawn, and at least one broad-spectrum IV antibiotic was administered. Among these patients, the mean age was 68 years, median hospital length of stay was 5 days, ED to ICU admission rate was 15%, and in-hospital mortality was 4.7%.
Overall, 196 patients (65%) were classified into “definite” (38%), or “likely” (27%) bacterial infections, and 104 patients (35%) were classified into “unlikely bacterial infection” (18%) or “definitely not infected” (16%). Within the groups that were classified as unlikely or definitely not infected, a significant number of patients were ultimately diagnosed with other conditions such as viral infections (28%) and volume overload/cardiac disease (9%).
This study underscores the challenge of diagnosing sepsis and reinforces that broad-spectrum antibiotics may not always be warranted for patients meeting “sepsis criteria.” However, this should not be viewed as a criticism of emergency providers. We often have very limited information, and our job is to be sensitive, not necessarily specific. This means that we frequently err on the side of the patient and lean towards over-treating vs under-treating.
Nevertheless, this is an important concept to address as we consider national sepsis guidelines and the increasing risk of antibiotic resistance.
Edited and Peer Reviewed by Sam Parnell
Likelihood of Bacterial Infection in Patients Treated With Broad-Spectrum IV Antibiotics in the Emergency Department. Crit Care Med. 2021 May 7. doi: 10.1097/CCM.0000000000005090. Online ahead of print.