Abstract
BackgroundThere is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes.MaterialThis study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock.ResultsA total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023).ConclusionsThe administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.
Highlights
There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis
A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI)
In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023)
Summary
There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. Severe sepsis and septic shock are worrisome manifestations of systemic infection and the leading causes of hospitalization in intensive care units (ICUs), where an estimated 19 million cases occur worldwide each year, resulting in the death of one in four of these patients [1,2]. Since 2006, we have utilized the sepsis bundle in our ICU [6], the treatment recommendations were organized in two bundles: a resuscitation bundle (6 tasks to begin immediately and to be accomplished within 6 hours) and a management bundle (4 tasks to be completed within 24 hours) [4]; there is no evaluation of the appropriateness of antimicrobial therapy after collecting blood cultures in sepsis bundle studies, which is one of the main measures to reduce mortality in critically ill patients suffering from infectious processes. When longer time frames to appropriate antibiotic therapy are observed there is an increased risk of death [7,8,9]
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