Madsen Tracy E, Napoli Anthony M
Division of Women's Health in Emergency Care, Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI; Department of Emergency Medicine, Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI.
Acad Emerg Med. 2014 Dec;21(12):1499-502. doi: 10.1111/acem.12546. Epub 2014 Nov 25.
Early antibiotics reduce mortality in patients with severe sepsis and septic shock. Recent work demonstrated that women experience greater delays to antibiotic administration, but it is unknown if this relationship remains after adjusting for factors such as source of infection.
The objective was to investigate whether gender and/or source of infection are associated with delays to antibiotics in patients with severe sepsis or septic shock.
This was a retrospective, observational study in an urban academic emergency department and national Surviving Sepsis Campaign (SSC) database study site. Consecutive patients age 18 years and older admitted to intensive care with severe sepsis or septic shock and entered into the SSC database from October 2005 to March 2012 were included. Two trained research assistants, blinded to the primary outcome, used a standardized abstraction form to obtain patient demographic and clinical data, including the Sequential Organ Failure Assessment (SOFA) scores and comorbidities. Time to first antibiotic and presumed source of infection were extracted from the SSC database. Univariate analyses were performed with Pearson chi-square tests and t-tests. Linear regression was performed with time to first antibiotic as the primary outcome. Covariates, chosen a priori by study authors, included age, race, ethnicity, source of infection, SOFA score, and lactate.
A total of 771 patients were included. Women were 45.3% of the sample, the mean age was 66 years (95% confidence interval [CI] = 65.1 to 67.5 years), 19.4% were nonwhite, and 8% were Hispanic. Mean time to first antibiotic was 153 minutes (95% CI = 143 to 163 minutes) for men and 184 minutes (95% CI = 171 to 197 minutes) for women (p < 0.001). The urinary tract was source of infection for 35.2% of women (95% CI = 30.2% to 40.3%) versus 23.7% (95% CI = 19.6% to 27.8%) of men. Pneumonia was present in 46.9% of men (95% CI = 42.1% to 51.7%) versus 35.8% (95% CI = 30.8% to 40.8%) of women. The mean time to antibiotics in women was longer than in men (adjusted odds ratio [aOR] = 1.18, 95% CI = 1.07 to 1.30), even after adjusting for age, race, ethnicity, presumed source of infection, SOFA score, and lactate (p = 0.001). Those with pneumonia compared to other infections received antibiotics faster (aOR = 0.73, 95% CI = 0.66 to 0.81). There was no significant association between other sources of infection and time to antibiotics in either univariate or multivariate analysis.
Women experience longer delays to initial antibiotics among patients with severe sepsis or septic shock, even after adjusting for infectious source. Pneumonia was associated with shorter times to antibiotic administration. Future research is necessary to investigate contributors to delayed antibiotic administration in women.
早期使用抗生素可降低严重脓毒症和脓毒性休克患者的死亡率。近期研究表明，女性在抗生素使用上的延迟时间更长，但在调整感染源等因素后，这种关系是否依然存在尚不清楚。
研究性别和/或感染源是否与严重脓毒症或脓毒性休克患者使用抗生素的延迟时间有关。
这是一项在城市学术急诊科及全国脓毒症存活行动（SSC）数据库研究点开展的回顾性观察性研究。纳入2005年10月至2012年3月期间因严重脓毒症或脓毒性休克入住重症监护病房并录入SSC数据库的18岁及以上连续患者。两名经过培训的研究助理在对主要结局不知情的情况下，使用标准化摘要表获取患者的人口统计学和临床数据，包括序贯器官衰竭评估（SOFA）评分及合并症。首次使用抗生素的时间及推测的感染源从SSC数据库中提取。采用Pearson卡方检验和t检验进行单因素分析。以首次使用抗生素的时间作为主要结局进行线性回归分析。研究作者预先选定的协变量包括年龄、种族、民族、感染源、SOFA评分和乳酸水平。
共纳入771例患者。女性占样本的45.3%，平均年龄为66岁（95%置信区间[CI]=65.1至67.5岁），19.4%为非白人，8%为西班牙裔。男性首次使用抗生素的平均时间为153分钟（95%CI=143至163分钟），女性为184分钟（95%CI=171至197分钟）（p<0.001）。女性中有35.2%（95%CI=30.2%至40.3%）的感染源为泌尿系统，而男性为23.7%（95%CI=19.6%至27.8%）。男性中有46.9%（95%CI=42.1%至51.7%）患有肺炎，女性为35.8%（95%CI=30.8%至40.8%）。即使在调整了年龄、种族、民族推测的感染源、SOFA评分和乳酸水平后，女性使用抗生素的平均时间仍长于男性（调整后的优势比[aOR]=1.18，95%CI=1.07至1.30）（p=0.001）。与其他感染相比，患有肺炎的患者使用抗生素更快（aOR=0.73，95%CI=0.66至0.81）。在单因素或多因素分析中，其他感染源与使用抗生素的时间之间均无显著关联。
即使在调整感染源后严重脓毒症或脓毒性休克患者中，女性在初始使用抗生素时的延迟时间更长。肺炎与抗生素使用时间较短有关。有必要开展进一步研究以探究导致女性抗生素使用延迟的因素。
