Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.
CIBER Enfermedades Respiratorias, Madrid, Spain.
Crit Care. 2018 Jun 22;22(1):167. doi: 10.1186/s13054-018-2091-0.
Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality.
We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs.
We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period.
Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
早期应用适当的抗生素治疗对脓毒症至关重要。我们旨在评估多方面教育干预措施对改善抗生素治疗的影响。我们假设该干预措施将加速并改善经验性抗生素治疗的适当性，有利于降级，并降低死亡率。
我们前瞻性地研究了西班牙 72 个重症监护病房（ICU）中所有连续的脓毒症/脓毒性休克患者，分为两个 4 个月的时间段（干预前和干预后 3 个月）。我们比较了两个队列的治疗过程变量（复苏捆绑和开始时间、经验性抗生素治疗的适当性和降级）和结局变量。主要结局是医院死亡率。我们在 50 个 ICU 的亚组中分析了干预的长期影响。
我们纳入了 2628 名患者（年龄 64.1±15.2 岁；男性 64.0%；急性生理学和慢性健康评估（APACHE）Ⅱ评分 22.0±8.1）：干预前队列 1352 例，干预后队列 1276 例。在干预后队列中，从脓毒症发病到经验性抗生素治疗的平均（SD）时间更短（2.0（2.7）比 2.5（3.6）小时；p=0.002），不适当的经验性治疗比例更低（6.5%比 8.9%；p=0.024），降级抗生素治疗的患者比例更高（20.1%比 16.3%；p=0.004）；预期死亡率降低没有达到统计学意义（干预后队列为 29.4%，干预前队列为 30.5%；p=0.544）。干预后观察到的收益在长期随访期间得到维持。
尽管脓毒症治疗取得了进展，但教育干预措施仍能改善治疗效果；进一步的改进也可能改善结局。
