Impact of compliance with infection management guidelines on outcome in patients with severe sepsis: a prospective observational multi-center study

Frank Bloos,Konrad Schwarzkopf,Karin Dey,Philipp Simon,Jürgen Eiche,Konrad Reinhart,Reimer Riessen,Didier Keh,Daniel Thomas-Rüddel,Manfred Weiß,Christoph Engel,Dirk Schädler,Daniel Schwarzkopf,Susanne Toussaint,Hendrik Rüddel,Heike Hoyer,A Weyland ,Christiane S Hartog ,Stéphan Juergen Harbarth ,M Ragaller ,Udo X Kaisers ,G E H Kuhnle ,John C Marshall

doi:10.1186/cc13755

Abstract

IntroductionCurrent sepsis guidelines recommend antimicrobial treatment (AT) within one hour after onset of sepsis-related organ dysfunction (OD) and surgical source control within 12 hours. The objective of this study was to explore the association between initial infection management according to sepsis treatment recommendations and patient outcome.MethodsIn a prospective observational multi-center cohort study in 44 German ICUs, we studied 1,011 patients with severe sepsis or septic shock regarding times to AT, source control, and adequacy of AT. Primary outcome was 28-day mortality.ResultsMedian time to AT was 2.1 (IQR 0.8 – 6.0) hours and 3 hours (-0.1 – 13.7) to surgical source control. Only 370 (36.6%) patients received AT within one hour after OD in compliance with recommendation. Among 422 patients receiving surgical or interventional source control, those who received source control later than 6 hours after onset of OD had a significantly higher 28-day mortality than patients with earlier source control (42.9% versus 26.7%, P <0.001). Time to AT was significantly longer in ICU and hospital non-survivors; no linear relationship was found between time to AT and 28-day mortality. Regardless of timing, 28-day mortality rate was lower in patients with adequate than non-adequate AT (30.3% versus 40.9%, P < 0.001).ConclusionsA delay in source control beyond 6 hours may have a major impact on patient mortality. Adequate AT is associated with improved patient outcome but compliance with guideline recommendation requires improvement. There was only indirect evidence about the impact of timing of AT on sepsis mortality.

Highlights

Current sepsis guidelines recommend antimicrobial treatment (AT) within one hour after onset of sepsis-related organ dysfunction (OD) and surgical source control within 12 hours
We aimed to assess compliance with recent bestpractice recommendations for the diagnosis and therapy of sepsis. Study design This prospective study was designed as a longitudinal multicenter observational cohort study in 42 German hospitals to determine the time to AT, surgical source control and compliance with sepsis recommendations related to AT in patients with suspected severe sepsis or septic shock and its impact on 28-day, ICU, and hospital mortality
37 patients were excluded for missing values in 28-day mortality or time to AT, resulting in 1,011 evaluable patients

Summary

Introduction

Current sepsis guidelines recommend antimicrobial treatment (AT) within one hour after onset of sepsis-related organ dysfunction (OD) and surgical source control within 12 hours. The objective of this study was to explore the association between initial infection management according to sepsis treatment recommendations and patient outcome. In the treatment of severe sepsis, timely and effective antimicrobial therapy (AT) as well as source control is crucial and has become a key element in the resuscitation bundles proposed by the Surviving Sepsis Campaign (SSC) [1]. The SSC guidelines recommend obtaining blood is associated with lower survival rates [7,8,9], but the appropriate time frame remains poorly defined [10]. The administration of antimicrobials within 1 hour was independently associated with a lower risk of hospital death [6]

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