Whiles Bristol B, Deis Amanda S, Simpson Steven Q
1University of Kansas School of Medicine, Kansas City, Kansas.2Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Kansas, Kansas City, Kansas.
Crit Care Med. 2017 Apr;45(4):623-629. doi: 10.1097/CCM.0000000000002262.
To determine if time to initial antimicrobial is associated with progression of severe sepsis to septic shock.
Retrospective cohort.
Six hundred fifty-six bed urban academic medical center.
Emergency department patients greater than or equal to 18 years old with severe sepsis and/or septic shock and antimicrobial administration within 24 hours. Patients with shock on presentation were excluded.
Not available.
We identified 3,929 severe sepsis patients, with overall mortality 12.8%. Nine hundred eighty-four patients (25.0%) progressed to septic shock. The median time to antimicrobial was 3.77 hours (interquartile range = 1.96-6.42) in those who progressed versus 2.76 hours (interquartile range = 1.60-4.82) in those who did not (p < 0.001). Multivariate logistic regression demonstrated that male sex (odds ratio = 1.18; 95% CI, 1.01-1.36), Charlson Comorbidity Index (odds ratio = 1.18; 95% CI, 1.11-1.27), number of infections (odds ratio = 1.05; 95% CI, 1.02-1.08), and time to first antimicrobial (odds ratio = 1.08; 95% CI, 1.06-1.10) were associated with progression. Each hour until initial antimicrobial administration was associated with a 8.0% increase in progression to septic shock. Additionally, time to broad-spectrum antimicrobial was associated with progression (odds ratio = 1.06; 95% CI, 1.05-1.08). Time to initial antimicrobial was also associated with in-hospital mortality (odds ratio = 1.05; 95% CI, 1.03-1.07).
This study emphasizes the importance of early, broad-spectrum antimicrobial administration in severe sepsis patients admitted through the emergency department, as longer time to initial antimicrobial administration is associated with increased progression of severe sepsis to septic shock and increased mortality.
确定开始使用抗菌药物的时间是否与严重脓毒症进展为脓毒性休克相关。
回顾性队列研究。
拥有656张床位的城市学术医疗中心。
年龄大于或等于18岁、患有严重脓毒症和/或脓毒性休克且在24小时内接受抗菌药物治疗的急诊科患者。就诊时即处于休克状态的患者被排除。
无。
我们识别出3929例严重脓毒症患者，总体死亡率为12.8%。984例患者（25.0%）进展为脓毒性休克。进展为脓毒性休克的患者开始使用抗菌药物的中位时间为3.77小时（四分位间距=1.96 - 6.42），未进展者为2.76小时（四分位间距=1.60 - 4.82）（p<0.001）。多因素logistic回归显示，男性（比值比=1.18；95%置信区间，1.01 - 1.36）、Charlson合并症指数（比值比=1.18；95%置信区间，1.11 - 1.27）、感染数量（比值比=1.05；95%置信区间，1.02 - 1.08）以及首次使用抗菌药物的时间（比值比=1.08；95%置信区间，1.06 - 1.10）与进展相关。直至开始使用抗菌药物的每一小时与进展为脓毒性休克的风险增加8.0%相关。此外，开始使用广谱抗菌药物的时间与进展相关（比值比=1.06；95%置信区间，1.05 - 1.08）。开始使用抗菌药物的时间也与住院死亡率相关（比值比=1.05；95%置信区间，1.03 - 1.07）。
本研究强调了对通过急诊科收治的严重脓毒症患者早期给予广谱抗菌药物治疗的重要性，因为开始使用抗菌药物的时间延长与严重脓毒症进展为脓毒性休克的风险增加以及死亡率升高相关。
