Capp Roberta, Chang Yuchiao, Brown David F M
Harvard Affiliated Emergency Medicine Residency Program, Brigham & Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA.
J Emerg Med. 2011 Dec;41(6):573-80. doi: 10.1016/j.jemermed.2010.10.024. Epub 2011 Mar 3.
Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.
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.
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.
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.
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.
在识别严重脓毒症和脓毒性休克的第一小时内进行抗生素选择已被证明可降低死亡率。
本研究的目的是确定正在使用哪些抗生素，并确定影响严重脓毒症或脓毒性休克患者抗生素覆盖无效的因素。此外，我们探索一种可改善病原体覆盖的抗生素选择替代方法。
这是一项对在12个月期间入住重症监护病房（ICU）的急诊科（ED）患者进行的回顾性研究，这些患者经培养确诊为严重脓毒症或脓毒性休克。适当的抗生素治疗定义为根据最终培养结果有效覆盖致病微生物。
在入住ICU的1400例患者中，137例培养结果呈阳性，符合严重脓毒症或脓毒性休克标准。急诊医生在82%（95%置信区间[CI].74-.88）的病例中开出了有效的抗生素覆盖处方。在25例接受无效抗生素治疗的患者中，大多数感染由耐药革兰氏阴性菌引起。无论感染源如何，所有患者均应用了医疗保健相关肺炎指南，该指南在选择由高度耐药菌引起感染的患者方面敏感度为100%（95%CI.93-1）。
急诊医生在严重脓毒症或脓毒性休克患者中实现了82%的有效抗生素覆盖。差距似乎在于对高度耐药革兰氏阴性菌的覆盖。发现一种利用社区和医疗保健相关感染指南的抗生素处方替代方法，在选择由耐药性更强的病原体引起感染的患者方面敏感度为100%。
