Pre-hospital Antibiotic Research Articles

Prehospital Antibiotic Administration for Suspected Open Fractures: Joint COT/OTA/ACEP/NAEMSP/NAEMT Position Statement

One of the primary concerns associated with open fractures is the development of a fracture-related infection (FRI). To minimize the risk of developing an FRI and subsequent morbidity, prophylactic antibiotics should be administered to patients with open fractures as soon as possible. While the antibiotic recommendations for severe open fractures are somewhat debatable, the use of a cephalosporin remains a mainstay of prophylactic treatment. Though administration of prehospital antibiotics does represent an expansion of EMS responsibilities, there have been several other treatment expansions in the prehospital setting, such as the administration of tranexamic acid and the application of pelvic binders. The administration of antibiotics, specifically cefazolin, is inexpensive, technically simple, and does not require special storage. The following recommendations are supported by and represent consensus of the COT, OTA, ACEP, NAEMSP and NAEMT with regards to prehospital antibiotic prophylaxis for suspected fractures: In a responsive patient with no history of penicillin or cephalosporin allergy, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life threats. This intervention should not delay transport. In an obtunded patient, the administration by EMS of a 1st generation cephalosporin should be performed after the management of life-threats. This intervention should not delay transport. In a responsive patient with a documented penicillin allergy, the administration by EMS of a 1st generation cephalosporin should be performed with close monitoring after the management of life-threats. This intervention should not delay transport.

Characterization of the Elderly Patients Admitted with Infection to a Tertiary Hospital in Bangladesh

Background: The proportion of hospitalizations attributable to infectious diseases is high, and likely to increase further in the future as a result of the expected aging of the population and the increasing prevalence of comorbid conditions among the elderly. The present study aimed to investigate the clinical characteristics and outcomes of elderly patients admitted due to infection in a tertiary-level hospital in Chattogram, Bangladesh. Materials and methods: This prospective observational study was conducted in Chittagong Medical College Hospital (CMCH) Chattogram. Two hundred and six patients aged ≥60 admitted with a diagnosis of infectious aetiology in the medicine department were enrolled according to set inclusion criteria. Patients were followed up for in-hospital outcomes after admission. Results: Age ranges from 60-90 years with a mean age of 65.82 (±5.56) years) and 51.5% were male. Pre-hospital antibiotic was received by 108 (52.4%) patients and 7.4% had antibiotic prescribed by registered physicians The most frequent infections were respiratory tract infections (47.6%) and urinary tract infections (43.2%). Sixty-four (31.1%) patients developed sepsis and 17 (8.3%) required ICU support. Eleven patients expired in-hospital, indicating a mortality rate of 5.3%. Length of hospitalization ranged from 2 to 17 days, with a median of 6 days. Conclusion: This study result suggests that infection-related hospitalization and outcomes of elderly individuals were high and their health seeking behaviour was poor. IAHS Medical Journal Vol 6(2), December 2023; 31-34

Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures

ABSTRACT Introduction Early administration of antibiotics for open fractures reduces serious bone and soft tissue infections. The effectiveness of antibiotics in reducing these infections is time-dependent, with various surgical associations recommending administration within one hour of injury, or within one hour of patient arrival to the emergency department (ED). The extent to which prehospital antibiotic administration in these situations might reduce the time to treatment has not been previously reported. The purpose of this study was to describe current prehospital use of antibiotics for traumatic injury, to assess the safety of prehospital antibiotic administration, and to estimate the potential time-savings associated with antibiotic administration by EMS clinicians. Methods This was a retrospective analysis of the 2019 through 2022 ESO Data Collaborative research data set. Included subjects were patients that had a linked ICD-10 code indicating an open extremity fracture and who received prehospital antibiotics. Time to antibiotic administration was calculated as the elapsed time from EMS dispatch until antibiotic administration. The minimum potential time saved by EMS antibiotic administration was calculated as the elapsed time from administration until ED arrival. To assess safety, epinephrine and diphenhydramine administration were used as proxies for the adverse events of anaphylaxis and minor allergic reactions. Results There were 523 patients meeting the inclusion criteria. The median (and interquartile range [IQR]) elapsed time from EMS dispatch until antibiotic administration was 31 (IQR: 24-41) minutes. The median potential time savings associated with prehospital antibiotic administration was 15 (IQR: 8-22) minutes. Notably, 144 (27.5%) of the patients who received prehospital antibiotics had total prehospital times exceeding one hour. None of the patients who received antibiotics also received epinephrine for presumed anaphylaxis. Conclusions EMS clinicians were able to safely administer antibiotics to patients with open fractures a median of 15 minutes before arrival at the hospital, and 99 percent of the patients receiving antibiotics had them administered within one hour of EMS dispatch. EMS administration of antibiotics may be a safe way to increase compliance with recommendations for early antibiotic administration for open fractures.

Associations with Prehospital Antibiotic Receipt among Combat Casualties with Open Wounds: A Department ofDefense Trauma Registry Study.

Current Tactical Combat Casualty Care (TCCC) guidelines recommend antibiotic administration for all open wounds to prevent infection. We identified associations between demographics, procedures, and medicines with the receipt of prehospital antibiotics among combat casualties. We used a series of emergency department procedure codes to identify adult subjects within the Department of Defense Trauma Registry from January 2007 to August 2016 who sustained open wounds. We compared demographics, procedures, and medicines administered among casualties receiving prehospital wound prophylaxis versus casualties not receiving antibiotic prophylaxis. We controlled for confounders with multivariable logistical regression. We identified 18,366 encounters meeting inclusion criteria. Antibiotic recipients (n = 2384) were comparable to nonrecipients (n = 15,982) with regard to age and sex. Antibiotic recipients were more likely to sustain injuries from firearms and undergo all procedures examined related to hemorrhage control, airway management, pneumothorax treatment, and volume replacement except for intraosseous access. Antibiotic recipients were less likely to sustain injuries from explosives. Antibiotic recipients had a modestly higher survival than nonrecipients (97.4% versus 96.0%). Associations with prehospital antibiotic receipt in multivariable logistic regression included non-North Atlantic Treaty Organization military force affiliation (odds ratio (OR) 4.65, 95% CI, 1.0-20.8), tachycardia (OR 3.4, 95% CI, 1.1-10.5), intubation (OR 2.0, 95% CI, 1.1-3.8), and administration of tranexamic acid (OR 5.6, 95% CI, 1.2-26.5). The proportion of combat casualties with open wounds receiving prehospital antibiotics was low despite published recommendations for early antibiotics in patients with open wounds. These findings highlight the ongoing need for additional educational and quality assurance initiatives to continue improving adherence to TCCC guidelines with regard to prehospital antibiotic administration. Future studies are necessary to determine reasons for suboptimal TCCC guideline compliance.

Invasiveness potential of pneumococcal serotypes in children after introduction of PCV13 in Blantyre, Malawi

IntroductionThe introduction of PCV13 to the Malawi infant immunization schedule in 2011 has been associated with reduced disease from Streptococcus pneumoniae. Improved understanding of serotypes with high invasive potential can guide future vaccination interventions. We aimed to estimate pneumococcal serotypes associated with acute respiratory infection (ARI) and invasive pneumococcal disease (IPD) in hospitalized children in Blantyre, Malawi.MethodsWe analysed data from healthy children under 5 years in the community in Blantyre and children admitted to Queen Elizabeth Central Hospital with ARI between 2015 and 2018. Nasopharyngeal swabs from children were tested for S. pneumoniae and serotyped by latex agglutination if positive. We analysed culture-positive blood and cerebrospinal fluid samples from admitted children between 2012 and 2018 to identify cases of IPD after the introduction of PCV13. We calculated the age-adjusted odds ratio (OR) of carriage for S. pneumoniae vaccine serotypes (VT) comparing those with ARI to healthy children. We also calculated age-adjusted ORs comparing serotypes causing IPD to carriage in the community with OR > 1 indicating high invasive potential.ResultsSerotypes 5 (OR 24.73 [95% CI 7.90–78.56] p < 0.001), 1 (OR 23.38 [95% CI 9.75–56.06] p < 0.001), and 6B (OR 4.73 [95% CI 1.66–11.64] p = 0.001) had high invasive potential. Serotype 6B was no longer significant (OR 1.34 [95% CI 0.07–6.87] p = 0.777) in a sensitivity analysis accounting for year of recruitment. The prevalence of S. pneumoniae carriage in the community was 72.6% [95% CI 71.3–74.0] (3078/4238) and 23.4% (719/3078) of positive community samples were VT. The carriage prevalence in those hospitalised with ARI was 45.5% [95% CI 42.1–48.9] (389/855) and 43.8% of hospital attendees reported antibiotic use prior to admission. We did not identify significant associations with carriage of any serotypes in those with ARI.ConclusionsPneumococcal serotypes 5 and 1 are associated with high invasive potential. Despite high community pneumococcal carriage, pre-hospital antibiotic usage likely reduces pneumococcal detection among children admitted in this setting and further research is needed to investigate serotypes associated with ARI. Data from this study can guide future preventative vaccination strategies in Malawi.

Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis.

Pneumonia is a leading cause of mortality in children <5 years globally. Early identification of hospitalized children with pneumonia who may fail antibiotics could improve outcomes. We conducted a secondary analysis from the Malawi CPAP IMPACT trial evaluating risk factors for antibiotic failure among children hospitalized with pneumonia. Participants were 1-59 months old with World Health Organization-defined severe pneumonia and hypoxemia, severe malnutrition, and/or HIV exposure/infection. All participants received intravenous antibiotics per standard care. First-line antibiotics were benzylpenicillin and gentamicin for five days. Study staff assessed patients for first-line antibiotic failure daily between days 3-6. When identified, patients failing antibiotics were switched to second-line ceftriaxone. Analyses excluded children receiving ceftriaxone and/or deceased by hospital day two. We compared characteristics between patients with and without treatment failure and fit multivariable logistic regression models to evaluate associations between treatment failure and admission characteristics. From June 2015-March 2018, 644 children were enrolled and 538 analyzed. Antibiotic failure was identified in 251 (46.7%) participants, and 19/251 (7.6%) died. Treatment failure occurred more frequently with severe malnutrition (50.2% (126/251) vs 28.2% (81/287), p<0.001) and amongst those dwelling ≥10km from a health facility (22.3% (56/251) vs 15.3% (44/287), p = 0.026). Severe malnutrition occurred more frequently among children living ≥10km from a health facility than those living <10km (49.0% (49/100) vs 35.7% (275/428), p = 0.014). Children with severe malnutrition (adjusted odds ratio (aOR) 2.2 (95% CI 1.52, 3.24), p<0.001) and pre-hospital antibiotics ((aOR 1.47, 95% CI 1.01, 2.14), p = 0.043) had an elevated aOR for antibiotic treatment failure. Severe malnutrition and pre-hospital antibiotic use predicted antibiotic treatment failure in this high-risk severe pneumonia pediatric population in Malawi. Our findings suggest addressing complex sociomedical conditions like severe malnutrition and improving pneumonia etiology diagnostics will be key for better targeting interventions to improve childhood pneumonia outcomes.

Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock.

This study aims to investigate the association between the 30-day mortality in patients with septic shock (SS) and a prehospital bundle of care completion, antibiotic therapy administration, and hemodynamic optimization defined as a fluid expansion of at least 10 mL.kg -1 .hr -1 . To assess the association between prehospital BUndle of Care (BUC) completion and 30-day mortality, the inverse probability treatment weighting (IPTW) propensity method was performed. International guidelines recommend early treatment implementation in order to reduce SS mortality. More than one single treatment, a bundle of care, including antibiotic therapy and hemodynamic optimization, is more efficient. From May 2016 to March 2021, patients with SS requiring prehospital mobile ICU (mICU) intervention were retrospectively analyzed. None. Among the 529 patients with SS requiring action by the mICU enrolled in this study, 354 (67%) were analyzed. Presumed pulmonary, digestive, and urinary infections were the cause of the SS in 49%, 25%, and 13% of the cases, respectively. The overall 30-day mortality was 32%. Seventy-one patients (20%) received prehospital antibiotic therapy and fluid expansion. Log binomial regression weighted with IPTW resulted in a significant association between 30-day mortality and prehospital BUC completion (respiratory rate [RR] of 0.56 [0.33-0.89]; p = 0.02 and adjusted RR 0.52 [0.27-0.93]; p = 0.03). A prehospital bundle of care, based on antibiotic therapy and hemodynamic optimization, is associated with a 30-day mortality decrease among patients suffering from SS cared for by an mICU.

Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis.

Background and AimsSome studies have suggested that earlier initiation of antibiotics has shown positive outcomes in sepsis patients. We aimed to do a systematic review and meta‐analysis to evaluate the effect of prehospital administration of antibiotics on 28 days mortality and length of stay in hospital and intensive care unit for sepsis patients.MethodsWe formulated a search strategy and used it on search databases PubMed, Scopus, Web of Science, and Embase. We then screened the records for eligibility and included controlled studies, either clinical trials or cohort studies reporting prehospital antibiotic administration for sepsis patients. We excluded duplicates, books, conferences' abstracts, case reports, editorials, letters, author responses, not English studies, and studies with nonavailable full text. Animal and lab studies were also excluded.ResultsThe total number of studies identified is 1811, 19 were eligible for systematic review and 4 for meta‐analysis (three cohort and one clinical trial). The total number of sepsis patients in the four included studies in the 28 days mortality outcome was 3523 (1779 took prehospital antibiotics and 1744 did not take prehospital antibiotics). Of 1779 who took the antibiotics, 190 died, and of 1744 who did not take antibiotics, 292 died (95% confidence interval 0.68–0.97, p = 0.02).ConclusionThis meta‐analysis reveals that receiving prehospital antibiotics can significantly lower mortality in sepsis patients compared to patients who do not receive prehospital antibiotics. However, more clinical trials and multicenter prospective studies with high sample sizes are needed to get strong evidence supporting our findings.

Adequacy of probabilistic prehospital antibiotic therapy for septic shock.

Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown. From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed. Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p=4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR=0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR=0.70 [0.53-0.93]. Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.

Comparison of prognostic factors between bacteraemic and non-bacteraemic critically ill immunocompetent patients in community-acquired severe pneumococcal pneumonia: a STREPTOGENE sub-study

BackgroundThe presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP.MethodsThis was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae. The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients.ResultsAmong 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups (p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates (p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone.ConclusionBacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors.

Etiology of viral respiratory tract infections in hospitalized adults, and evidence of the high frequency of prehospitalization antibiotic treatment in Norway.

Background and aimsRespiratory tract infections (RTIs) cause considerable morbidity and mortality in all age groups, but the epidemiology and role of several of the viral RTIs in the adult and elderly patients are still unclear, as is the extent of prehospitalization antibacterial drug use in this population.MethodsWe conducted a three‐year (2015‐2018) observational study of viral RTIs in hospitalized patients in a 500‐bed hospital in Southeastern Norway, including all patients ≥18 years with RTI symptoms where one of the following viral agents was detected in a respiratory specimen (Seegene Allplex): Influenza A/B, RSV A/B, human metapneumovirus (hMPV), adenovirus and parainfluenza virus 1‐4. Viral findings, demographical data, and information on prehospital antibiotic prescriptions were recorded.ResultsIn 1182 patients 1222 viral infection events occurred. The mean patient age was 69.6 years, and 53% were females. Influenza virus A/B (63%), RSV A/B (15%) and hMPV (13%) were the most common agents detected. The proportional burden of influenza A H1 was found to be relatively high (65%) in the age groups <69 years, compared to older patients (P = .001, chi‐square).As many as 20% of the patients had been treated with antibiotics prior to admission, with the lowest rate for influenza A H3 group at 17% (P = .036, chi‐square), and highest for the RSV group at 28% (P = .004, chi‐square).Oseltamivir was prescribed prior to hospitalization in only 3 cases (0.2%).ConclusionsWe found a high rate of prehospital antibiotic prescription in adults hospitalized with viral RTIs, warranting better stewardship programs to tackle the increasing antibiotic resistance problem.

To study the incidence of pre-hospital antibiotic therapy among critically ill patients admitted in rural tertiary care hospital

There is considerate amount of stress which lies in the application of antibiotics in critically ill patients. A study on pre-hospital antibiotic administration in such patients would provide crucial data and go a long way in determining and understanding trends in antibiotic prescribing, to identify where necessary steps to be taken to improve prescribing are most needed and to measure progress. After ethical committee approval, we have conducted an observational cross-sectional study for four months. We collected the data from patient or the relatives regarding prehospital antibiotic therapy on admission.A total of 137 patients got admitted in the Medical intensive care unit (MICU) during the study period. Out of them, 91.24% of patients got admitted directly in MICU and 8.75% were referred from different hospitals. Those who received antibiotics prior to the admission were 2.18% and 93.43% of patients had not received antibiotics; the other patients who were not sure of antibiotic consumption were 4.37%. Among those 2.18% of patients who received, it was observed the most commonly utilized first antibiotic in our study was amoxicillin clavulanate potassium 66.66%. In all the patients that received more than one antibiotic, Metronidazole was the second antibiotic that was administered via intravenous route. Amoxicillin clavulanate potassium was the most commonly and metronidazole was the second most antibiotic prescribed in prehospital admission. Proper guidelines should be initiated for the starting of the antibiotic therapies in India for general practitioners.

Effect of Prehospital Antibiotic Therapy on Clinical Outcome and Pathogen Detection in Children With Parapneumonic Pleural Effusion/Pleural Empyema.

Parapneumonic pleural effusion and pleural empyema (PPE/PE) are complications of community-acquired pneumonia. The objective of this study was to analyze prehospital antibiotic therapy (PH-ABT) of children with PPE/PE and investigate its effects on clinical outcome and pathogen detection. Prospective nationwide active surveillance in Germany between October 2010 and June 2018. Children and adolescents <18 years of age with pneumonia-associated PE or PPE requiring drainage or with persistence of PPE/PE >7 days were included. A total of 1724 children with PPE/PE were reported, of whom 556 children (32.3% of 1719 with available data) received PH-ABT. Children with PH-ABT had a shorter median hospital length of stay (15 vs. 18 days, P < 0.001), a longer time from onset of symptoms until hospital discharge (25 vs. 23 days, P = 0.002), a lower rate of intensive care unit admission (58.3% vs. 64.4%, P = 0.015) and fewer infectious complications (5.9% vs. 10.0%; P = 0.005). Bacterial pathogens in blood or pleural fluid culture were detected in 597 (34.5%) of 1513 children. Positive culture results were less frequent in children with than without PH-ABT (81/466 [17.4%] vs. 299/1005 [29.8%]; P < 0.001), whereas detection rates in pleural fluid samples by polymerase chain reaction were similar (91/181 [50.3%] vs. 220/398 [55.3%]; P = 0.263). In children with PPE/PE, PH-ABT significantly reduced the overall rate of bacterial pathogen detection by culture, but not by polymerase chain reaction. PH-ABT was associated with a lower rate of infectious complications but did not affect the overall duration of disease. We therefore speculate that the duration of PPE/PE is mainly a consequence of an infection-induced inflammatory process, which can only partially be influenced by antibiotic treatment.

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality

Background Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. Methods From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Results Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). Conclusion In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.

Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance

IntroductionSevere open tibial fractures are limb-threatening injuries. Outcomes depend on a complex interplay of patient, injury and treatment factors. 2009 guidelines from the British Orthopaedic Association (BOA) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommend prophylactic intravenous antibiotic administration within three hours of injury. More recent National Institute for Health and Care Excellence (NICE) 2016 guidelines recommend pre-hospital antibiotic administration where possible. This study aimed to analyse the impact of time to antibiotics on development of deep infection. MethodsAdult acute Gustilo-Anderson 3B open tibial fractures managed at a single UK Major Trauma Centre were reviewed retrospectively over a three-year period, including a period before and after the regional ambulance service introduced a policy of administering pre-hospital intravenous antibiotics to open fractures in 2016. Development of deep infection was recorded as the primary outcome measure. Complete case regression analysis was performed. Time was assessed as a continuous variable and as thresholds with antibiotics received within one or three hours of injury. Results156 patients with 159 fractures were included. Following introduction of new guidance in 2016, median time to antibiotics decreased from 180 to 160 min and more patients received pre-hospital antibiotics (2% vs. 33%). Overall, 7.5% developed deep infection (n = 12) within a median follow-up of 26 months. Logistic regression found no relationship between any independent variable, including time to antibiotic administration, and development of deep infection. ConclusionsThere are a variety of factors identified in the literature and in national policies and treatment guidelines as potentially modifiable to reduce the risk of deep infection following open fractures. In this study, time to antibiotic administration was not associated with the risk of developing deep infection. The results of this study demonstrate a low infection rate, which may be due to expedient expert care delivered by a dedicated orthoplastic service in line with national guidance where achievable.

The clinical impact of PCR-based point-of-care diagnostic in respiratory tract infections in children.

BackgroundChildren are commonly affected by respiratory tract infections. Based on clinical symptoms, laboratory evaluation, and imaging, the causative pathogen often cannot be delineated. Point‐of‐care‐testing systems that provide an opportunity for fast detection of common viruses and some bacteria can therefore influence treatment's options. We aimed to examine whether the Biofire® FilmArray® has an effect on antibiotic treatment, duration of antibiotic therapy, and length of hospital stay within a pediatric cohort.MethodsWe included children who were admitted to inpatient treatment with an acute respiratory tract infection from 02/2017 to 04/2018 using the FA respiratory panel for pathogen detection. The study group data were compared to the retrospective data of children admitted from 02/2016 to 02/2017, using a proprietary multiplex RT‐PCR.ResultsA total of 322 children of the study group and 464 children of the control group were analyzed for clinical symptoms, laboratory findings, antibiotic treatment, and length of hospital stay. There was no significant reduction (P < .05) of antibiotic treatment and length of hospital stay. CRP, prehospital antibiotic treatment, antibiotic treatment, past medical history, age, and further pathogen detection showed a significant impact on antibiotic therapy, duration of antibiotic treatment, and length of hospital stay.ConclusionThe use of the FA did not result in a significant reduction of antibiotic treatment or in length of hospital stay. Other parameters had a more significant impact. Therefore, we suggest that standard operation procedures with therapy guidelines are necessary to provide an effective application of POCT systems.

Pediatric Odontogenic Infections and Prescription Antibiotic Use

Objectives: In the past several years worldwide, the discussion has developed about antibiotic resistance. Dentists, although a small percentage of the prescribers of antibiotics, can play a role in reducing antibiotic use and therefore help address this growing problem. Highly variable prescription practices illustrate the dentist’s contribution to the overuse of antibiotics. An investigation into antibiotic use and subsequent effects on clinical presentation odontogenic infections. Described are the variances in the clinical presentation of subjects who received antibiotics and those that had no antimicrobial therapy before presentation in the hospital setting. Methods: A retrospective chart review was conducted for subjects who presented with odontogenic infections to a children’s hospital emergency department. Variables collected were: pre-hospital antibiotic use, vital signs on admission, site of infection, quality of infection, and dental involvement. Results: 112 subjects: 73 male and 39 females. 49 received pre-hospital antibiotics while 63 did not have previous antibiotic therapy. Pre-hospital antimicrobials consisted of 10 different types of antibiotic therapies. No significance was found between the two groups and the clinical presentation of infection or admission vital signs. Conclusion: High variability of antibiotic use for orofacial infections was observed including the type of antimicrobial utilized and prescribing provider (non-dentist). This study provided information correlating patient physiology and the lack of clinical impact by pre-hospital antibiotic use. Due to high variability in providers' type administering antibiotic prescriptions and irregular drug and dosage practices, detailed practice guidelines and antibiotic stewardship programs should be augmented for assistance concerning odontogenic infection treatments.

EMS Prehospital Blood Culture Collection and Antibiotic Administration: A Two-Phase Pilot Project to Reduce Mortality in Patients With Severe Sepsis and Septic Shock

EMS Prehospital Blood Culture Collection and Antibiotic Administration: A Two-Phase Pilot Project to Reduce Mortality in Patients With Severe Sepsis and Septic Shock

Impact of pre-hospital antibiotic therapy on mortality in invasive meningococcal disease: a propensity score study.

The role of pre-hospital antibiotic therapy in invasive meningococcal diseases remains unclear with contradictory data. The aim was to determine this role in the outcome of invasive meningococcal disease. Observational cohort study ofpatients with/without pre-hospital antibiotic therapy in invasive meningococcal disease attended at the Hospital Universitari de Bellvitge (Barcelona) during the period 1977-2013. Univariate and multivariate analyses of mortality, corrected by propensity score used as a covariate to adjust for potential confounding, were performed. Patients with pre-hospital antibiotic therapy were also analyzed according to whether they had received oral (group A) or parenteral antibiotics (early therapy) (group B). Five hundred twenty-seven cases of invasive meningococcal disease were recorded and 125 (24%) of them received pre-hospital antibiotic therapy. Shock and age were the risk factors independently related to mortality. Mortality differed between patients with/without pre-hospital antibiotic therapy (0.8% vs. 8%, p= 0.003). Pre-hospital antibiotic therapy seemed to be a protective factor in the multivariate analysis of mortality (p= 0.038; OR, 0.188; 95% CI, 0.013-0.882). However, it was no longer protective when the propensity score was included in the analysis (p= 0.103; OR, 0.173; 95% CI, 0.021-1.423). Analysis of the oral and parenteral pre-hospital antibiotic groups revealed that there were no deaths in early therapy group. Patients able to receive oral antibiotics had less severe symptoms than those who did not receive pre-hospital antibiotics. Age and shock were the factors independently related to mortality. Early parenteral therapy was not associated with death. Oral antibiotic therapy in patients able to take it was associated with a beneficial effect in the prognosis of invasive meningococcal disease.

Can pre-hospital administration reduce time to initial antibiotic therapy in septic patients?

To quantify the potential time saved with pre-hospital antibiotic therapy in sepsis. Study data for adult patients transported by Ambulance Victoria (AV), and enrolled into the Australasian Resuscitation In Sepsis Evaluation (ARISE), were linked with pre-hospital electronic records. An AV record was identified for 240 of 341 ARISE patients. The pre-hospital case notes referred to potential infection in 165 patients. The median time to first antibiotic administration from loading the patient into the ambulance was 107 (74-160) min. ARISE patients in Victoria were frequently identified pre-hospital. An opportunity exists to study the feasibility of pre-hospital antibiotic therapy.