Leisman Daniel, Huang Victor, Zhou Qiuping, Gribben Jeanie, Bianculli Andrea, Bernshteyn Michelle, Ward Mary Frances, Schneider Sandra M
1Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, NY. 2Icahn School of Medicine at Mount Sinai, New York, NY. 3State University of New York Upstate Medical University, Syracuse, NY. 4Department of Neurosurgery, Hofstra-Northwell School of Medicine, Hempstead, NY. 5Feinstein Institute for Medical Research, Manhasset, NY. 6American College of Emergency Physicians, Irving, TX.
Crit Care Med. 2017 Jun;45(6):956-965. doi: 10.1097/CCM.0000000000002377.
Retrospective, consecutive sample sepsis cohort over 10 months.
Single, tertiary, academic medical center.
All patients admitted from the emergency department with sepsis or septic shock (defined: infection, ≥ 2 systemic inflammatory response syndrome criteria, hypoperfusion/organ dysfunction) identified by a prospective quality initiative.
less than 18 years old, not receiving initial antibiotics in the emergency department, death before antibiotic redosing, and patient refusing antibiotics.
We determined first-to-second antibiotic time and delay frequency. We considered delay major for first-to-second dose time greater than or equal to 25% of the recommended interval. Factors of interest were demographics, recommended interval length, comorbidities, clinical presentation, location at second dose, initial resuscitative care, and antimicrobial activity mechanism.
Of 828 sepsis cases, 272 (33%) had delay greater than or equal to 25%. Delay frequency increased dose dependently with shorter recommended interval: 11 (4%) delays for 24-hour intervals (median time, 18.52 hr); 31 (26%) for 12-hour intervals (median, 10.58 hr); 117 (47%) for 8-hour intervals (median, 9.60 hr); and 113 (72%) for 6-hour intervals (median, 9.55 hr). In multivariable regression, interval length significantly predicted major delay (12 hr: odds ratio, 6.98; CI, 2.33-20.89; 8 hr: odds ratio, 23.70; CI, 8.13-69.11; 6 hr: odds ratio, 71.95; CI, 25.13-206.0). Additional independent risk factors were inpatient boarding in the emergency department (odds ratio, 2.67; CI, 1.74-4.09), initial 3-hour sepsis bundle compliance (odds ratio, 1.57; CI, 1.07-2.30), and older age (odds ratio, 1.16 per 10 yr, CI, 1.01-1.34). In the exploratory multivariable analysis, major delay was associated with increased hospital mortality (odds ratio, 1.61; CI, 1.01-2.57) and mechanical ventilation (odds ratio, 2.44; CI, 1.27-4.69).
Major second dose delays were common, especially for patients given shorter half-life pharmacotherapies and who boarded in the emergency department. They were paradoxically more frequent for patients receiving compliant initial care. We observed association between major second dose delay and increased mortality, length of stay, and mechanical ventilation requirement.
1）确定脓毒症入院患者第二次使用抗生素的延迟频率和延迟时长；2）识别这些延迟的风险因素；3）探索性研究：确定延迟与以患者为中心的结局（死亡率和第二次给药后的机械通气）之间的关联。
为期10个月的回顾性连续样本脓毒症队列研究。
单一的三级学术医疗中心。
通过一项前瞻性质量改进计划确定的所有因脓毒症或脓毒性休克从急诊科入院的患者（定义为：感染、满足≥2条全身炎症反应综合征标准、存在灌注不足/器官功能障碍）。
年龄小于18岁、在急诊科未接受初始抗生素治疗、在重新给药前死亡以及患者拒绝使用抗生素。
我们确定了首次给药至第二次给药的时间以及延迟频率。若首次给药至第二次给药的时间大于或等于推荐间隔时间的25%，则我们将其视为严重延迟。感兴趣的因素包括人口统计学特征、推荐间隔时长、合并症、临床表现、第二次给药时所在位置、初始复苏治疗以及抗菌活性机制。
在828例脓毒症病例中，272例（33%）出现了大于或等于25%的延迟。延迟频率随推荐间隔时间缩短呈剂量依赖性增加：24小时间隔时有11例（4%）延迟（中位时间为18.52小时）；12小时间隔时有31例（26%）延迟（中位时间为10.58小时）；8小时间隔时有117例（47%）延迟（中位时间为9.60小时）；6小时间隔时有113例（72%）延迟（中位时间为9.55小时）。在多变量回归分析中，间隔时长显著预测了严重延迟（12小时：比值比为6.98；可信区间为2.33 - 20.89；8小时：比值比为23.70；可信区间为8.13 - 69.11；6小时：比值比为71.95；可信区间为25.13 - 206.0）。其他独立风险因素包括在急诊科住院（比值比为2.67；可信区间为1.74 - 4.09）、最初3小时内脓毒症集束治疗的依从性（比值比为1.57；可信区间为1.07 - 2.30）以及年龄较大（每增加10岁比值比为1.16；可信区间为1.01 - 1.34）。在探索性多变量分析中，严重延迟与医院死亡率增加（比值比为1.61；可信区间为1.01 - 2.57）和机械通气（比值比为2.44；可信区间为1.27 - 4.69）相关。
第二次给药的严重延迟很常见，尤其是对于接受半衰期较短药物治疗且在急诊科住院的患者。矛盾的是，接受初始治疗依从性较好的患者延迟更为频繁。我们观察到第二次给药严重延迟与死亡率增加、住院时间延长以及机械通气需求增加之间存在关联。
