Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA.
Center for Adult Critical Care (CACC), Virginia Commonwealth University, Richmond, VA.
Crit Care Med. 2019 Oct;47(10):1388-1395. doi: 10.1097/CCM.0000000000003921.
There is mounting evidence that delays in appropriate antimicrobial administration are responsible for preventable deaths in patients with sepsis. Herein, we examine the association between potentially modifiable antimicrobial administration delays, measured by the time from the first order to the first administration (antimicrobial lead time), and death among people who present with new onset of sepsis.
Observational cohort and case-control study.
The emergency department of an academic, tertiary referral center during a 3.5-year period.
Adult patients with new onset of sepsis or septic shock.
None.
We enrolled 4,429 consecutive patients who presented to the emergency department with a new diagnosis of sepsis. We defined 0-1 hour as the gold standard antimicrobial lead time for comparison. Fifty percent of patients had an antimicrobial lead time of more than 1.3 hours. For an antimicrobial lead time of 1-2 hours, the adjusted odds ratio of death at 28 days was 1.28 (95% CI, 1.07-1.54; p = 0.007); for an antimicrobial lead time of 2-3 hours was 1.07 (95% CI, 0.85-1.36; p = 0.6); for an antimicrobial lead time of 3-6 hours was 1.57 (95% CI, 1.26-1.95; p < 0.001); for an antimicrobial lead time of 6-12 hours was 1.36 (95% CI, 0.99-1.86; p = 0.06); and for an antimicrobial lead time of more than 12 hours was 1.85 (95% CI, 1.29-2.65; p = 0.001).
Delays in the first antimicrobial execution, after the initial clinician assessment and first antimicrobial order, are frequent and detrimental. Biases inherent to the retrospective nature of the study apply. Known biologic mechanisms support these findings, which also demonstrate a dose-response effect. In contrast to the elusive nature of sepsis onset and sepsis onset recognition, antimicrobial lead time is an objective, measurable, and modifiable process.
越来越多的证据表明，适当的抗菌药物治疗延迟是导致脓毒症患者可预防死亡的原因。在此，我们研究了从首次医嘱到首次给药（抗菌药物前置时间）之间潜在可改变的抗菌药物给药延迟与新发脓毒症患者死亡之间的关系。
观察性队列和病例对照研究。
在 3.5 年期间，一所学术性三级转诊中心的急诊部。
新诊断为脓毒症或脓毒性休克的成年患者。
无。
我们纳入了 4429 例连续就诊于急诊部的新诊断为脓毒症的患者。我们将 0-1 小时定义为抗菌药物前置时间的金标准，用于比较。50%的患者抗菌药物前置时间超过 1.3 小时。抗菌药物前置时间为 1-2 小时时，28 天死亡的调整比值比为 1.28（95%置信区间，1.07-1.54；p=0.007）；抗菌药物前置时间为 2-3 小时时为 1.07（95%置信区间，0.85-1.36；p=0.6）；抗菌药物前置时间为 3-6 小时时为 1.57（95%置信区间，1.26-1.95；p<0.001）；抗菌药物前置时间为 6-12 小时时为 1.36（95%置信区间，0.99-1.86；p=0.06）；抗菌药物前置时间超过 12 小时时为 1.85（95%置信区间，1.29-2.65；p=0.001）。
从最初的临床评估和首次抗菌药物医嘱到首次执行抗菌药物之间的延迟是常见且有害的。研究的回顾性固有偏见适用。已知的生物学机制支持这些发现，也证明了剂量反应效应。与脓毒症发作和脓毒症发作识别的难以捉摸的性质相比，抗菌药物前置时间是一个客观、可测量和可改变的过程。
