Impact of Appropriate Antibiotics within One Hour and Patients' Outcome: A Study and Review

Abstract

Background: Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock & bacterial meningitis. The initiation of treatment with inappropriate antimicrobial agents (in relation to the subsequently demonstrated sensitivity of the pathogen) as the initial empiric therapy may be the single most common cause of prolonged delays in the introduction of effective therapy. Only in 5% of cases were antibiotics administered within 1 hr of the decision making, in 47% of cases it took 1-2 hrs. Only in 33% of cases antibiotics were prescribed within one hour of decision making. In 95% of cases antibiotics were administered within one hour of prescription. Sepsis is the main cause of death in patients treated in intensive care units (ICU). Current sepsis guidelines recommend administration of antibiotics within one hour of ED triage. However, the quality of supporting evidence is moderate & studied have shown mixed results regarding the association between antibiotics administration timing & outcome in septic shock. Objective: The aim of this study was to assess whether timing of administration of appropriate antibiotics within one hour of admission to the ICU impact patient outcomes. Method: Timing of ICU admission noted from the patient’s ICU nursing chart when the first vital parameters are noted by the nurse. Timing of administration of 1st dose of antibiotic and antibiotic that is administered within the first one hour of admission is noted from ICU nursing chart (in minutes from the timing of ICU admission). Appropriateness of antibiotic is assessed from the microbiology culture and sensitivity result. Outcome measures is noted from the ICU database. Data is then recorded systemically in the data collection form and finally entered in the excel sheet for analysis. All the data is then analysed by statistician by appropriate statistical tests. Result: A total of 53 patients, including 63.2% in the sepsis group and 53.4% in the septic shock group received antibiotics within the first hour. 87.5 % patients who received antibiotic within one hour of admission were discharged compared to 81.0% patients who received first dose of antibiotic beyond one hour of admission. The commonest gram-negative organisms were E. coli and Klebsiella in both groups. The commonest antibiotic administered was Meropenem in both groups. All patients who received appropriate antibiotic were discharged compared with only 69.2% patients discharged whose antibiotic choice was inappropriate. Mortality was 30.8% in the group whose initial antibiotic choice was inappropriate while no patients died in the group where the patient received appropriate empirical therapy. Conclusion: In my study it is demonstrated that gram-negative bacteria remain the major pathogen in sepsis as has been demonstrated in most ICUs in India. When appropriateness as well as timing of administration were compared simultaneously, all patients who received appropriate antibiotic within one hour or more than one hour survived to discharge. However, if antibiotic choice was inappropriate, 25% patients died even if they received the antibiotics within one hour and if the first dose was delayed beyond the first hour, the mortality further increased to 40%. There was no significant difference in the mean of ICU length of stay and mean hospital length of stay of patients based on appropriateness of empirical antibiotic therapy.