Antibiotics for ICU Patients with Sepsis or Septic Shock
Antibiotics for ICU Patients with Sepsis or Septic Shock
Background Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.
Objective The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage.
Methods This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results.
Results Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms.
Conclusion Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.
Sepsis is the second leading cause of death in non-coronary intensive care unit (ICU) patients. It carries a high mortality rate and costs approximately $17 billion annually in the United States alone. The Surviving Sepsis Campaign recommends initiating broad-spectrum antibiotics targeted toward the source of infection within the first hour of recognition of septic shock. This recommendation (now level 1B) is based on two retrospective studies showing that effective antibiotic initiation has been shown to decrease mortality when administered within the first hour of identified septic shock.
Because many patients who have septic shock or severe sepsis remain in the emergency department (ED) for several hours, the role of the emergency physician in rapidly selecting appropriate antibiotics for administration may be critical in lowering the mortality rate in patients diagnosed with septic shock or severe sepsis.
The goal of this study was to determine whether first-line antibiotics selected by emergency physicians effectively covered disease-causing organisms in patients presenting to the ED with septic shock or severe sepsis. We evaluated the types of antibiotics given and identified the antibiotics that were not effective. We built an antibiogram of all organisms causing infections in patients with severe sepsis or septic shock to identify a potential group of organisms that were not being effectively treated (i.e., the gap). Finally, we explored an alternative method of antibiotic selection based on predicting organism resistance by using a set of guidelines to separate patients into two groups: health care-associated infections (potentially infected with more resistant organisms) vs. community-acquired infections (potentially infected with less resistant organisms).
Abstract and Introduction
Abstract
Background Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.
Objective The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage.
Methods This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results.
Results Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93–1) for selecting patients who had infections caused by highly resistant organisms.
Conclusion Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.
Introduction
Sepsis is the second leading cause of death in non-coronary intensive care unit (ICU) patients. It carries a high mortality rate and costs approximately $17 billion annually in the United States alone. The Surviving Sepsis Campaign recommends initiating broad-spectrum antibiotics targeted toward the source of infection within the first hour of recognition of septic shock. This recommendation (now level 1B) is based on two retrospective studies showing that effective antibiotic initiation has been shown to decrease mortality when administered within the first hour of identified septic shock.
Because many patients who have septic shock or severe sepsis remain in the emergency department (ED) for several hours, the role of the emergency physician in rapidly selecting appropriate antibiotics for administration may be critical in lowering the mortality rate in patients diagnosed with septic shock or severe sepsis.
The goal of this study was to determine whether first-line antibiotics selected by emergency physicians effectively covered disease-causing organisms in patients presenting to the ED with septic shock or severe sepsis. We evaluated the types of antibiotics given and identified the antibiotics that were not effective. We built an antibiogram of all organisms causing infections in patients with severe sepsis or septic shock to identify a potential group of organisms that were not being effectively treated (i.e., the gap). Finally, we explored an alternative method of antibiotic selection based on predicting organism resistance by using a set of guidelines to separate patients into two groups: health care-associated infections (potentially infected with more resistant organisms) vs. community-acquired infections (potentially infected with less resistant organisms).
